Provider Demographics
NPI:1255053245
Name:SAMUEL, KRYSTAL (BCBA)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:GREENTREE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48143-0663
Mailing Address - Country:US
Mailing Address - Phone:810-599-2129
Mailing Address - Fax:
Practice Address - Street 1:350 PINECREST ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1328
Practice Address - Country:US
Practice Address - Phone:989-278-8878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician