Provider Demographics
NPI:1760784490
Name:LARSEN, KRYSTAL A (BCBA)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:A
Last Name:LARSEN
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 1:4602 N ARMENIA AVE
Mailing Address - Street 2:C
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2626
Mailing Address - Country:US
Mailing Address - Phone:813-957-1160
Mailing Address - Fax:
Practice Address - Street 1:4602 N ARMENIA AVE
Practice Address - Street 2:C
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2626
Practice Address - Country:US
Practice Address - Phone:813-957-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-10-3900103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst