Provider Demographics
NPI:1114201159
Name:COLLETTE, CRYSTAL AMY (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:AMY
Last Name:COLLETTE
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:AMY
Other - Last Name:CASCARINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, BCBA, LBA
Mailing Address - Street 1:1354 8TH ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-1812
Mailing Address - Country:US
Mailing Address - Phone:434-363-5306
Mailing Address - Fax:
Practice Address - Street 1:1354 8TH ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-1812
Practice Address - Country:US
Practice Address - Phone:434-363-5306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000276103K00000X
1-11-8012103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst