Provider Demographics
NPI:1396419842
Name:BLACK, KAYLA (BCBA)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:
Other - Last Name:SCHAFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RBT
Mailing Address - Street 1:1324 20TH AVE SW STE 2
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-6452
Mailing Address - Country:US
Mailing Address - Phone:701-858-0009
Mailing Address - Fax:
Practice Address - Street 1:1324 20TH AVE SW STE 2
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6452
Practice Address - Country:US
Practice Address - Phone:701-858-0009
Practice Address - Fax:701-516-8462
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRBT-21-171917106S00000X
NDL85103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician