Healthcare Provider Details

I. General information

NPI: 1447020169
Provider Name (Legal Business Name): ROBERT BRIDGLAL ENNIS RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301A W PALMETTO PARK RD STE 100C
BOCA RATON FL
33433-3403
US

IV. Provider business mailing address

4370 NW 80TH AVE UNIT B
CORAL SPRINGS FL
33065-1935
US

V. Phone/Fax

Practice location:
  • Phone: 954-248-1171
  • Fax:
Mailing address:
  • Phone: 954-934-8998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-313931
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: