Healthcare Provider Details

I. General information

NPI: 1164220364
Provider Name (Legal Business Name): KRISTINA RAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SALEM ST
LAFAYETTE IN
47904-2147
US

IV. Provider business mailing address

2000 GREENBUSH ST
LAFAYETTE IN
47904-2255
US

V. Phone/Fax

Practice location:
  • Phone: 765-420-1400
  • Fax:
Mailing address:
  • Phone: 765-423-5531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-149806
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: