Provider Demographics
NPI:1265734230
Name:WALSTROM, KRISTEN AMANDA (MA, BCBA)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:AMANDA
Last Name:WALSTROM
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:AMANDA
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, BCBA
Mailing Address - Street 1:16707 MARCUS ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7617
Mailing Address - Country:US
Mailing Address - Phone:907-854-5889
Mailing Address - Fax:907-696-9913
Practice Address - Street 1:911 BLANCO CIR
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-4449
Practice Address - Country:US
Practice Address - Phone:831-540-3491
Practice Address - Fax:831-998-7682
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-24
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
1-06-2877103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-06-2877OtherBOARD CERTIFIED BEHAVIOR ANALYST (BCBA)