Provider Demographics
NPI:1235552704
Name:KACZKA, KAYLA LEE (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:LEE
Last Name:KACZKA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:MS
Other - First Name:KAYLA
Other - Middle Name:LEE
Other - Last Name:GLENN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1740 S GLENSTONE AVE
Mailing Address - Street 2:SUITE S
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1511
Mailing Address - Country:US
Mailing Address - Phone:417-890-1399
Mailing Address - Fax:417-890-1775
Practice Address - Street 1:1740 S GLENSTONE AVE
Practice Address - Street 2:SUITE S
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1511
Practice Address - Country:US
Practice Address - Phone:417-890-1399
Practice Address - Fax:417-890-1775
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014003096103K00000X
MO2015015158103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst