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NPI Code Detail

MEDICARE: KRYSTAL SAMUEL BCBA

MEDICARE: KRYSTAL SAMUEL BCBA
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
1106S00000XBehavior Technician
2103K00000XBehavior Analyst

General Provider Information

NPI Number : 1255053245
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRYSTAL SAMUEL BCBA
Provider Business Mailing Address
First Line : PO BOX 663
Second Line :
City : LAKELAND
State : MI
Zip : 48143-0663
Country : US
Telephone Number : 810-599-2129
Fax Number :
Provider Business Practice Location Address
First Line : 350 PINECREST ST
Second Line :
City : ALPENA
State : MI
Zip : 49707-1328
Country : US
Telephone Number : 989-278-8878
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/15/2022
Last Update Date : 03/03/2025

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Directions to “ KRYSTAL SAMUEL BCBA” Practice Location

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