Healthcare Provider Details

I. General information

NPI: 1669830360
Provider Name (Legal Business Name): KRISTIN M RANDY BCBA,LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 11/03/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12625 WALROND RD
FISHERS IN
46037-6632
US

IV. Provider business mailing address

12625 WALROND RD
FISHERS IN
46037-6632
US

V. Phone/Fax

Practice location:
  • Phone: 541-241-6446
  • Fax:
Mailing address:
  • Phone: 541-241-6446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-34941
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberABA-IN-10174842
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: