Provider Demographics
NPI:1992039663
Name:LAGOR, CRYSTAL
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:LAGOR
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:LAGOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCABA
Mailing Address - Street 1:4518 S MANHATTAN AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-2306
Mailing Address - Country:US
Mailing Address - Phone:813-835-4591
Mailing Address - Fax:813-832-3427
Practice Address - Street 1:4518 S MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-2306
Practice Address - Country:US
Practice Address - Phone:813-835-4591
Practice Address - Fax:813-832-3427
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-0802547103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst