MEDICARE: CHRISTINA IMGRUND M.A., BCBA

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	106S00000X	Behavior Technician
2	103K00000X	Behavior Analyst	1-19-40207

General Provider Information

NPI Number	:	1528595733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA IMGRUND M.A., BCBA

Provider Business Mailing Address
First Line	:	5895 S HARRINGTON WAY
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83709-6096
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1967 S CREEKSIDE LN
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83706-4036
Country	:	US
Telephone Number	:	805-668-8957
Fax Number	:

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

Provider Enumeration Date	:	05/18/2017
Last Update Date	:	07/21/2022

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