Provider Demographics
NPI:1982443123
Name:GODBOUT, KRYSTLE (BCBA)
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:GODBOUT
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 NICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:ENOSBURG FALLS
Mailing Address - State:VT
Mailing Address - Zip Code:05450-5047
Mailing Address - Country:US
Mailing Address - Phone:802-528-6332
Mailing Address - Fax:
Practice Address - Street 1:2017 NICHOLS RD
Practice Address - Street 2:
Practice Address - City:ENOSBURG FALLS
Practice Address - State:VT
Practice Address - Zip Code:05450-5047
Practice Address - Country:US
Practice Address - Phone:802-528-6332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT146.0134108103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst