Basic Information
| Provider Information | |||||||||
| NPI: | 1508129107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNELLY | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | ERIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CONNELLY-REALI | ||||||||
| OtherFirstName: | CARRIE | ||||||||
| OtherMiddleName: | ERIN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S., BCBA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 345 SHERWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | SATELLITE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329373037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219605882 | ||||||||
| FaxNumber: | 3217734487 | ||||||||
| Practice Location | |||||||||
| Address1: | 527 N MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371302833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 3175208200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2012 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-04-2044 | FL | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 1013 | TN | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.