Healthcare Provider Details

I. General information

NPI: 1538693593
Provider Name (Legal Business Name): KRISTINA LARSSON MA, BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11140 S TOWNE SQ SUITE 100
SAINT LOUIS MO
63123-7830
US

IV. Provider business mailing address

1031 S GABOURI ST
SAINTE GENEVIEVE MO
63670-1465
US

V. Phone/Fax

Practice location:
  • Phone: 314-845-3900
  • Fax: 314-845-3901
Mailing address:
  • Phone: 573-608-0484
  • Fax: 314-845-3901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2017010137
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2017010137
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: