Provider Demographics
NPI:1093247314
Name:ECKERSALL, KRYSTINA
Entity Type:Individual
Prefix:MISS
First Name:KRYSTINA
Middle Name:
Last Name:ECKERSALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48-35 213 STREET
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1233
Mailing Address - Country:US
Mailing Address - Phone:718-640-8814
Mailing Address - Fax:
Practice Address - Street 1:4835 213TH ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE HILLS
Practice Address - State:NY
Practice Address - Zip Code:11364-1233
Practice Address - Country:US
Practice Address - Phone:718-640-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician