MEDICARE: MISS KRYSTINA ECKERSALL

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		NY

General Provider Information

NPI Number	:	1093247314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KRYSTINA ECKERSALL

Provider Business Mailing Address
First Line	:	48-35 213 STREET
Second Line	:
City	:	BAYSIDE HILLS
State	:	NY
Zip	:	11364-1233
Country	:	US
Telephone Number	:	718-640-8814
Fax Number	:

Provider Business Practice Location Address
First Line	:	4835 213TH ST
Second Line	:
City	:	BAYSIDE HILLS
State	:	NY
Zip	:	11364-1233
Country	:	US
Telephone Number	:	718-640-8814
Fax Number	:

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

Provider Enumeration Date	:	03/28/2017
Last Update Date	:	03/28/2017

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Directions to “ MISS KRYSTINA ECKERSALL ” Practice Location

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