MEDICARE: MRS. CRYSTAL LAGOR

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	103K00000X	Behavior Analyst	1-18-33026	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992039663
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRYSTAL LAGOR

Provider Business Mailing Address
First Line	:	4518 S MANHATTAN AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33611-2306
Country	:	US
Telephone Number	:	813-835-4591
Fax Number	:	813-832-3427

Provider Business Practice Location Address
First Line	:	10135 MONTAGUE ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-1857
Country	:	US
Telephone Number	:	813-401-2539
Fax Number	:	813-492-7330

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

Provider Enumeration Date	:	09/28/2009
Last Update Date	:	04/08/2025

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