Basic Information
| Provider Information | |||||||||
| NPI: | 1356957872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNELLY | ||||||||
| FirstName: | RANDI | ||||||||
| MiddleName: | ALEXIS | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 HEMLOCK TERRACE RUN | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344726271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525255749 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1650 W MAIN ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347482842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523143760 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2020 | ||||||||
| LastUpdateDate: | 11/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-20-45554 | FL | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 1-20-45554 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 019666100 | 05 | FL | MEDICAID |