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NPI Code Detail

MEDICARE: EMILY ROSE BOLT MS, BCBA

MEDICARE: EMILY ROSE BOLT MS, BCBA
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 Analyst
2103K00000XBehavior Analyst1-19-35273GA

General Provider Information

NPI Number : 1912469131
Entity Type Code : Individual
Provider Name (Legal Business Name) : EMILY ROSE BOLT MS, BCBA
Provider Business Mailing Address
First Line : 300 INTERNATIONAL PKWY STE 200
Second Line :
City : LAKE MARY
State : FL
Zip : 32746-5028
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4000 SMITHTOWN RD STE 200
Second Line :
City : SUWANEE
State : GA
Zip : 30024-6560
Country : US
Telephone Number : 470-632-4990
Fax Number : 317-520-8200
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/05/2019
Last Update Date : 08/24/2020

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