Healthcare Provider Details

I. General information

NPI: 1346527793
Provider Name (Legal Business Name): LORI ANN BOLT BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ARC DR
ST AUGUSTINE FL
32084-0512
US

IV. Provider business mailing address

1747 MANDARIN ESTATES DR
JACKSONVILLE FL
32223-5549
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-7249
  • Fax: 904-824-8063
Mailing address:
  • Phone: 386-846-8407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-09-6450
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: