Healthcare Provider Details

I. General information

NPI: 1396419842
Provider Name (Legal Business Name): KAYLA BLACK BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLA SCHAFFER RBT

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 20TH AVE SW STE 2
MINOT ND
58701-6452
US

IV. Provider business mailing address

1324 20TH AVE SW STE 2
MINOT ND
58701-6452
US

V. Phone/Fax

Practice location:
  • Phone: 701-858-0009
  • Fax: 701-516-8462
Mailing address:
  • Phone: 701-858-0009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberL85
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-171917
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: