Healthcare Provider Details

I. General information

NPI: 1093551350
Provider Name (Legal Business Name): BLUE BOLT PEDIATRIC CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2024
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ELGIN RD APT 1218
EVANSTON IL
60201-5628
US

IV. Provider business mailing address

1555 SHERMAN AVE # 324
EVANSTON IL
60201-4421
US

V. Phone/Fax

Practice location:
  • Phone: 917-580-2599
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: EMILY GROBEN
Title or Position: BOARD CERTIFIED BEHAVIOR ANALYST
Credential: M.S. ED., BCBA
Phone: 917-580-2599