1235552704 NPI number — MRS. KAYLA LEE KACZKA BCBA

Table of content: MRS. KAYLA LEE KACZKA BCBA (NPI 1235552704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235552704 NPI number — MRS. KAYLA LEE KACZKA BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KACZKA
Provider First Name:
KAYLA
Provider Middle Name:
LEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GLENN
Provider Other First Name:
KAYLA
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235552704
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1740 S GLENSTONE AVE
Provider Second Line Business Mailing Address:
SUITE S
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65804-1511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-890-1399
Provider Business Mailing Address Fax Number:
417-890-1775

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1740 S GLENSTONE AVE
Provider Second Line Business Practice Location Address:
SUITE S
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-1511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-890-1399
Provider Business Practice Location Address Fax Number:
417-890-1775
Provider Enumeration Date:
02/03/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  2014003096 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X , with the licence number: 2015015158 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)