Provider Demographics
NPI:1730654922
Name:WAGNER, KAYLA DIANE (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:DIANE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:DIANE
Other - Last Name:BRACHBILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, BCBA
Mailing Address - Street 1:902 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-2210
Mailing Address - Country:US
Mailing Address - Phone:618-937-6483
Mailing Address - Fax:
Practice Address - Street 1:902 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896
Practice Address - Country:US
Practice Address - Phone:855-608-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-19-35267103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst