Provider Demographics
NPI:1497218168
Name:BURKERT, CRYSTAL L (BCBA)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:L
Last Name:BURKERT
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 1:125 COLTS NECK RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07727-3638
Mailing Address - Country:US
Mailing Address - Phone:856-469-1374
Mailing Address - Fax:
Practice Address - Street 1:125 COLTS NECK RD
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NJ
Practice Address - Zip Code:07727
Practice Address - Country:US
Practice Address - Phone:856-469-1374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ11833702103K00000X
NJ1-18-33072103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-18-33072OtherBEHAVIOR ANALYST CERTIFICIATION BOARD