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NPI Code Detail

MEDICARE: JUSTINE ANNA RANDALL BCBA, LABA, LBA

MEDICARE: JUSTINE ANNA RANDALL BCBA, LABA, LBA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103K00000XBehavior Analyst2330MA
2103K00000XBehavior Analyst84CT

General Provider Information

NPI Number : 1578864021
Entity Type Code : Individual
Provider Name (Legal Business Name) : JUSTINE ANNA RANDALL BCBA, LABA, LBA
Provider Business Mailing Address
First Line : 18 BILLINGS RD
Second Line :
City : SOMERS
State : CT
Zip : 06071-1924
Country : US
Telephone Number : 617-291-6149
Fax Number :
Provider Business Practice Location Address
First Line : 835 BLOOMFIELD AVE
Second Line :
City : WINDSOR
State : CT
Zip : 06095-2363
Country : US
Telephone Number : 860-413-9538
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/14/2010
Last Update Date : 08/22/2024

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