=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104301118
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAITLYN BURYLO MA, BCBA, LBS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2018
-----------------------------------------------------
Last Update Date | 09/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2601 HERR ST
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17103-1815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-701-2501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 417 S UNION ST
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17057-1372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-701-2501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-17-27692
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------