Provider Demographics
NPI:1659934677
Name:WALLINGFORD, KYLEE (BCBA)
Entity Type:Individual
Prefix:
First Name:KYLEE
Middle Name:
Last Name:WALLINGFORD
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KYLEE
Other - Middle Name:
Other - Last Name:MERRITTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2140 BUFORD HWY
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-6120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2140 BUFORD HWY
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-6120
Practice Address - Country:US
Practice Address - Phone:678-230-1447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-19-35497103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst