Provider Demographics
NPI:1912620014
Name:CONERLY, MYKAYLA COURTNEY (MED, MS, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:MYKAYLA
Middle Name:COURTNEY
Last Name:CONERLY
Suffix:
Gender:F
Credentials:MED, MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BOUTELLE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4808
Mailing Address - Country:US
Mailing Address - Phone:207-745-4408
Mailing Address - Fax:
Practice Address - Street 1:16 BOUTELLE AVE APT 1
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4808
Practice Address - Country:US
Practice Address - Phone:207-745-4408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1-21-56226103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst