MEDICARE: BOLT BEHAVIOR 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568909497
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLT BEHAVIOR SERVICES

Provider Business Mailing Address
First Line	:	1747 MANDARIN ESTATES DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-5549
Country	:	US
Telephone Number	:	386-846-8407
Fax Number	:

Provider Business Practice Location Address
First Line	:	1747 MANDARIN ESTATES DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-5549
Country	:	US
Telephone Number	:	386-846-8407
Fax Number	:	904-770-4882

Authorized Official
Title or Position	:	OWNER
Name	:	LORI ANN BOLT
Credential	:	BCBA
Telephone Number	:	386-846-8407

Provider Enumeration Date	:	01/30/2017
Last Update Date	:	05/19/2025

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