MEDICARE: KRYSTAL CASEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	2023016783	MO

General Provider Information

NPI Number	:	1154012961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL CASEY

Provider Business Mailing Address
First Line	:	2240 COUNTY ROAD 1270
Second Line	:
City	:	WILLOW SPRINGS
State	:	MO
Zip	:	65793-3393
Country	:	US
Telephone Number	:	573-883-6761
Fax Number	:

Provider Business Practice Location Address
First Line	:	2240 COUNTY ROAD 1270
Second Line	:
City	:	WILLOW SPRINGS
State	:	MO
Zip	:	65793-3393
Country	:	US
Telephone Number	:	573-883-6761
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2023
Last Update Date	:	05/15/2023

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Directions to “ KRYSTAL CASEY ” Practice Location

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