Provider Demographics
NPI:1295234979
Name:SAMPICA-MANOR, CRYSTAL MAY (MS BCBA NYS-LBA)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:MAY
Last Name:SAMPICA-MANOR
Suffix:
Gender:F
Credentials:MS BCBA NYS-LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3665 MILITARY TPKE
Mailing Address - Street 2:
Mailing Address - City:WEST CHAZY
Mailing Address - State:NY
Mailing Address - Zip Code:12992-2807
Mailing Address - Country:US
Mailing Address - Phone:518-493-3558
Mailing Address - Fax:
Practice Address - Street 1:3665 MILITARY TPKE
Practice Address - Street 2:
Practice Address - City:WEST CHAZY
Practice Address - State:NY
Practice Address - Zip Code:12992-2807
Practice Address - Country:US
Practice Address - Phone:518-493-3558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000801-1103K00000X
1-15-18047103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst