Provider Demographics
NPI:1740679638
Name:WALCZAK, KAITLIN (MA, BCBA)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:WALCZAK
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 GREENBRIAR LN
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-1681
Mailing Address - Country:US
Mailing Address - Phone:215-704-9224
Mailing Address - Fax:
Practice Address - Street 1:154 GREENBRIAR LN
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1681
Practice Address - Country:US
Practice Address - Phone:215-704-9224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-14
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI11410030103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst