Provider Demographics
NPI:1326712175
Name:KELLEY, KRYSTAL
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17128 WINDWARD BLVD UNIT 201
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-5038
Mailing Address - Country:US
Mailing Address - Phone:302-296-8427
Mailing Address - Fax:
Practice Address - Street 1:1 SUSSEX AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-1853
Practice Address - Country:US
Practice Address - Phone:302-503-3120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
DE1-22-59809103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician