Provider Demographics
NPI:1154012961
Name:CASEY, KRYSTAL
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:CASEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 COUNTY ROAD 1270
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:65793-3393
Mailing Address - Country:US
Mailing Address - Phone:573-883-6761
Mailing Address - Fax:
Practice Address - Street 1:2240 COUNTY ROAD 1270
Practice Address - Street 2:
Practice Address - City:WILLOW SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:65793-3393
Practice Address - Country:US
Practice Address - Phone:573-883-6761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023016783103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst