MEDICARE: BOLD CITY BEHAVIORAL SERVICES

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
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1982293544
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLD CITY BEHAVIORAL SERVICES

Provider Business Mailing Address
First Line	:	4136 TRIESTE PL
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32244-2325
Country	:	US
Telephone Number	:	904-240-6800
Fax Number	:

Provider Business Practice Location Address
First Line	:	4136 TRIESTE PL
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32244-2325
Country	:	US
Telephone Number	:	904-240-6800
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AMELIA NELSON
Credential	:	BCBA
Telephone Number	:	904-240-6800

Provider Enumeration Date	:	01/18/2021
Last Update Date	:	01/18/2021

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Directions to “BOLD CITY BEHAVIORAL SERVICES ” Practice Location

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