Provider Demographics
NPI:1568965671
Name:WALLACE, KAYLA (BCBA)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:MARIE
Other - Last Name:FLADGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RBT
Mailing Address - Street 1:1500 E HAMILTON AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-0834
Mailing Address - Country:US
Mailing Address - Phone:831-234-8537
Mailing Address - Fax:
Practice Address - Street 1:1500 E HAMILTON AVE STE 105
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-0834
Practice Address - Country:US
Practice Address - Phone:831-234-8537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
1-21-54042103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician