Provider Demographics
NPI:1881113629
Name:ACT LIFE TRANSITIONS
Entity type:Organization
Organization Name:ACT LIFE TRANSITIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO OF CLINICAL PROGRAM DEVELOPMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:ERIN
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:321-265-7557
Mailing Address - Street 1:2965 LIMPET CT
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-1825
Mailing Address - Country:US
Mailing Address - Phone:321-265-7557
Mailing Address - Fax:
Practice Address - Street 1:2965 LIMPET CT
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-1825
Practice Address - Country:US
Practice Address - Phone:321-265-7557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-04-2044103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-04-2044OtherBEHAVIOR ANALYSIS CERTIFICATION BOARD