Provider Demographics
NPI:1568950616
Name:PETRIE, KAYLA A (BCBA)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:A
Last Name:PETRIE
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 1:54 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-5644
Mailing Address - Country:US
Mailing Address - Phone:508-287-4105
Mailing Address - Fax:781-385-7324
Practice Address - Street 1:54 LAKE DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-5644
Practice Address - Country:US
Practice Address - Phone:508-287-4105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2462103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician