Provider Demographics
NPI:1114319936
Name:RANDOL, RENEE ELIZABETH BLIVEN (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:ELIZABETH BLIVEN
Last Name:RANDOL
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1117
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-0965
Mailing Address - Country:US
Mailing Address - Phone:401-529-3078
Mailing Address - Fax:
Practice Address - Street 1:324 SHIPPEETOWN RD
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-1118
Practice Address - Country:US
Practice Address - Phone:401-529-3078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-03
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015002575103K00000X
RILBA00081103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst