Provider Demographics
NPI:1912408139
Name:TERRY, KAITLYN ELISE (MA, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:KAITLYN
Middle Name:ELISE
Last Name:TERRY
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 1:3650 MT DIABLO BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3768
Mailing Address - Country:US
Mailing Address - Phone:916-923-1789
Mailing Address - Fax:
Practice Address - Street 1:3650 MT DIABLO BLVD STE 107
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3768
Practice Address - Country:US
Practice Address - Phone:805-443-7124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-18-47223106S00000X
CA1-20-43427103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician