Healthcare Provider Details

I. General information

NPI: 1184014698
Provider Name (Legal Business Name): CRYSTAL CHRISTENSEN BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19204 N CREEK PKWY STE 110
BOTHELL WA
98011-8009
US

IV. Provider business mailing address

PO BOX 767938
ROSWELL GA
30076-7938
US

V. Phone/Fax

Practice location:
  • Phone: 818-241-6780
  • Fax: 800-819-7806
Mailing address:
  • Phone: 818-241-6780
  • Fax: 800-819-7806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0-14-6249
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBA61146569
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: