Provider Demographics
NPI:1487156535
Name:WYNN, KAYLA R (RBT)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:R
Last Name:WYNN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:R
Other - Last Name:ATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:3441 FORT CAMPBELL BLVD STE F3
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-6684
Mailing Address - Country:US
Mailing Address - Phone:931-449-0063
Mailing Address - Fax:
Practice Address - Street 1:3441 FORT CAMPBELL BLVD STE F3
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-6684
Practice Address - Country:US
Practice Address - Phone:931-449-0063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-20-40961103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1-20-40961OtherBEHAVIOR ANALYST CERTIFICATION BOARD (BACB)