Healthcare Provider Details

I. General information

NPI: 1194205930
Provider Name (Legal Business Name): CRYSTALYN LAZO BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

373 S WILLOW ST STE 266
MANCHESTER NH
03103-5751
US

IV. Provider business mailing address

373 S WILLOW ST STE 266
MANCHESTER NH
03103-5751
US

V. Phone/Fax

Practice location:
  • Phone: 877-315-8080
  • Fax:
Mailing address:
  • Phone: 877-315-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2021041483
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-56144
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-53103
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: