Provider Demographics
NPI:1104637826
Name:KRYSTAL JAVIER SAMUEL, LLC
Entity type:Organization
Organization Name:KRYSTAL JAVIER SAMUEL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BCBA
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:JAVIER SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-330-7639
Mailing Address - Street 1:200 CONTINENTAL PKWY APT 311
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4540
Mailing Address - Country:US
Mailing Address - Phone:719-330-7639
Mailing Address - Fax:
Practice Address - Street 1:200 CONTINENTAL PKWY APT 311
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4540
Practice Address - Country:US
Practice Address - Phone:719-330-7639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty