Provider Demographics
NPI:1881255131
Name:LEE, KRISTA JADE (BCBA)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:JADE
Last Name:LEE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:KRANZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:935 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-2126
Mailing Address - Country:US
Mailing Address - Phone:773-759-3964
Mailing Address - Fax:
Practice Address - Street 1:300 N 10TH ST
Practice Address - Street 2:
Practice Address - City:GAS CITY
Practice Address - State:IN
Practice Address - Zip Code:46933-1605
Practice Address - Country:US
Practice Address - Phone:888-877-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-45125103K00000X
103K00000X
IN0-19-9898106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst