Provider Demographics
NPI:1982212916
Name:MERCADO, KHRYSTA G (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:KHRYSTA
Middle Name:G
Last Name:MERCADO
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 JOHN OLDS DR APT 110
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-8808
Mailing Address - Country:US
Mailing Address - Phone:860-670-8966
Mailing Address - Fax:
Practice Address - Street 1:281 ROUTE 163
Practice Address - Street 2:
Practice Address - City:UNCASVILLE
Practice Address - State:CT
Practice Address - Zip Code:06382-2119
Practice Address - Country:US
Practice Address - Phone:860-933-5751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-20-43250103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst