Provider Demographics
NPI:1568243244
Name:BADILLO REGAN, KRYSTAL ELIZABETH (PHD)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:ELIZABETH
Last Name:BADILLO REGAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 WESTFIELD DR
Mailing Address - Street 2:
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-2113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-0001
Practice Address - Country:US
Practice Address - Phone:603-650-5133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1677103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist