Provider Demographics
NPI:1285170647
Name:TERRIQUEZ, KAYLA IRENE (MS, BCBA)
Entity type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:IRENE
Last Name:TERRIQUEZ
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 LILLY RD
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-1214
Mailing Address - Country:US
Mailing Address - Phone:262-483-1773
Mailing Address - Fax:
Practice Address - Street 1:1496 W MEQUON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3268
Practice Address - Country:US
Practice Address - Phone:414-881-8435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI165-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst