Provider Demographics
NPI:1124363544
Name:ANDERSON, KRYSTLE (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8710 EULALIE AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2012
Mailing Address - Country:US
Mailing Address - Phone:314-486-2311
Mailing Address - Fax:
Practice Address - Street 1:650 OFFICE PKWY
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7103
Practice Address - Country:US
Practice Address - Phone:314-486-2311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012039557103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst