Provider Demographics
NPI:1508129107
Name:CONNELLY, CARRIE ERIN (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ERIN
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:MS
Other - First Name:CARRIE
Other - Middle Name:ERIN
Other - Last Name:CONNELLY-REALI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, BCBA
Mailing Address - Street 1:345 SHERWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SATELLITE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-3037
Mailing Address - Country:US
Mailing Address - Phone:321-960-5882
Mailing Address - Fax:321-773-4487
Practice Address - Street 1:527 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-2833
Practice Address - Country:US
Practice Address - Phone:855-324-0885
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-04-2044103K00000X
TN1013103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst