Provider Demographics
NPI:1639618895
Name:BOLDEN, STEPHANIE DANIELLE (BCBA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DANIELLE
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:D
Other - Last Name:BOLDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:813-512-1153
Mailing Address - Fax:
Practice Address - Street 1:1140 KYLE WOOD LN
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4850
Practice Address - Country:US
Practice Address - Phone:813-512-1153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-20
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
FL172V00000X405300000X
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL172V00000XOtherOTHER PROVIDER COMMUNITY HEALTH CARE WORKER