Provider Demographics
NPI:1568909497
Name:BOLT BEHAVIOR SERVICES
Entity Type:Organization
Organization Name:BOLT BEHAVIOR SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR BEHAVIOR ANALYST
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-846-8407
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:904-770-4882
Practice Address - Street 1:741 AUSTIN PL
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-5472
Practice Address - Country:US
Practice Address - Phone:386-846-8407
Practice Address - Fax:904-770-4882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017607800Medicaid