Provider Demographics
NPI:1790491413
Name:NELSON, KRYSTA (BCBA)
Entity Type:Individual
Prefix:
First Name:KRYSTA
Middle Name:
Last Name:NELSON
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 1:2 BARKLAND DR
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-3936
Mailing Address - Country:US
Mailing Address - Phone:603-216-4533
Mailing Address - Fax:
Practice Address - Street 1:200 GRIFFIN RD STE 5
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7145
Practice Address - Country:US
Practice Address - Phone:800-778-5560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHBACB691873103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst