Provider Demographics
NPI:1376009266
Name:MOLINA-LOMELI, CRYSTAL (BCBA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MOLINA-LOMELI
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 1:1703 FOUNTAINVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5092
Mailing Address - Country:US
Mailing Address - Phone:817-385-7170
Mailing Address - Fax:
Practice Address - Street 1:1703 FOUNTAINVIEW DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5092
Practice Address - Country:US
Practice Address - Phone:817-385-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-21-56257103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-19-75373OtherBACB