Provider Demographics
NPI:1356957872
Name:CONNELLY, RANDI ALEXIS (BCBA)
Entity type:Individual
Prefix:MS
First Name:RANDI
Middle Name:ALEXIS
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:3001 W SILVER SPRINGS BLVD BLDG 200
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34475-5647
Practice Address - Country:US
Practice Address - Phone:352-358-3700
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-45554103K00000X
1-20-45554103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019666100Medicaid