Provider Demographics
NPI:1235995986
Name:BOYLAN, BRIDGET MICHELLE (RBT)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:MICHELLE
Last Name:BOYLAN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1759 POINCIANA CIR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-1124
Mailing Address - Country:US
Mailing Address - Phone:321-349-7176
Mailing Address - Fax:
Practice Address - Street 1:454 FORT FLORIDA RD
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-9714
Practice Address - Country:US
Practice Address - Phone:386-968-2012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-03-20
Deactivation Date:2024-02-21
Deactivation Code:
Reactivation Date:2024-03-20
Provider Licenses
StateLicense IDTaxonomies
FLBACB1054829103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst