Provider Demographics
NPI:1710428842
Name:WELCH-HEANEY, KYLA (LBA)
Entity Type:Individual
Prefix:
First Name:KYLA
Middle Name:
Last Name:WELCH-HEANEY
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 767938
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-7938
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:800-819-7806
Practice Address - Street 1:19204 N CREEK PKWY STE 110
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-8009
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:800-819-7806
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
WABA61131264103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician