Provider Demographics
NPI:1245780089
Name:KELLY, CAROLINE CONN (BCBA)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:CONN
Last Name:KELLY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 SCOTTS RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-6577
Mailing Address - Country:US
Mailing Address - Phone:704-609-4456
Mailing Address - Fax:
Practice Address - Street 1:309 SCOTTS RIDGE TRL
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-6577
Practice Address - Country:US
Practice Address - Phone:704-609-4456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC86-2675055OtherIRS