Healthcare Provider Details

I. General information

NPI: 1407687528
Provider Name (Legal Business Name): THEODORE LOUIS BJORNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2024
Last Update Date: 08/10/2024
Certification Date: 08/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

782 FOXRIDGE CENTER DR
ORANGE PARK FL
32065-5776
US

IV. Provider business mailing address

6930 WINTERBERRY CT
KEYSTONE HEIGHTS FL
32656-8672
US

V. Phone/Fax

Practice location:
  • Phone: 904-637-1400
  • Fax:
Mailing address:
  • Phone: 408-713-8195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-368251
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: