Provider Demographics
NPI:1346527793
Name:BOLT, LORI ANN (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:ANN
Last Name:BOLT
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 AUSTIN PL
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-5472
Mailing Address - Country:US
Mailing Address - Phone:386-846-8407
Mailing Address - Fax:
Practice Address - Street 1:2101 ARC DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-0512
Practice Address - Country:US
Practice Address - Phone:904-824-7249
Practice Address - Fax:904-824-8063
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-09-6450103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst