Provider Demographics
NPI:1598285439
Name:ALCANTARA, KRISTINE (BCABA)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:ALCANTARA
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-6247
Mailing Address - Country:US
Mailing Address - Phone:337-842-4485
Mailing Address - Fax:
Practice Address - Street 1:2519 RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7323
Practice Address - Country:US
Practice Address - Phone:337-491-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0-17-7797106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst