Provider Demographics
NPI:1215409610
Name:CONNELLY, CAITLIN ELIZABETH (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:ELIZABETH
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 WARWICK TPKE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-3918
Mailing Address - Country:US
Mailing Address - Phone:215-588-5472
Mailing Address - Fax:
Practice Address - Street 1:122 WARWICK TPKE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-3918
Practice Address - Country:US
Practice Address - Phone:215-588-5472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-23
Last Update Date:2018-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001643-1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty