Basic Information
| Provider Information | |||||||||
| NPI: | 1164938403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOLFESE | ||||||||
| FirstName: | KRYSTA | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21505 N 78TH AVE STE 125 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853823356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232078108 | ||||||||
| FaxNumber: | 6232495004 | ||||||||
| Practice Location | |||||||||
| Address1: | 21505 N 78TH AVE STE 125 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232078108 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2017 | ||||||||
| LastUpdateDate: | 11/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | BCBA-1-18-32469 | AZ | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | RBT-17-41612 | AZ | N |
No ID Information.