Provider Demographics
NPI:1194205930
Name:LAZO, CRYSTALYN (BCBA)
Entity Type:Individual
Prefix:
First Name:CRYSTALYN
Middle Name:
Last Name:LAZO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:373 S WILLOW ST STE 266
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-5751
Mailing Address - Country:US
Mailing Address - Phone:877-315-8080
Mailing Address - Fax:
Practice Address - Street 1:373 S WILLOW ST STE 266
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-5751
Practice Address - Country:US
Practice Address - Phone:877-315-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021041483103K00000X
LARBT-18-56144106S00000X
NJ1-21-53103103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician