Provider Demographics
NPI:1144889338
Name:KOUKOULIS, ANASTASIA (MAT)
Entity type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:
Last Name:KOUKOULIS
Suffix:
Gender:F
Credentials:MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3359 CHEVERLY COURT
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009
Mailing Address - Country:US
Mailing Address - Phone:727-366-0323
Mailing Address - Fax:
Practice Address - Street 1:3359 CHEVERLY CT
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:MD
Practice Address - Zip Code:21009-2854
Practice Address - Country:US
Practice Address - Phone:727-366-0323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics