Provider Demographics
NPI:1679028773
Name:GLINES, EDYMAR DANIELLE (BCBA)
Entity Type:Individual
Prefix:
First Name:EDYMAR
Middle Name:DANIELLE
Last Name:GLINES
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 1:3370 BEAU RIVAGE DR APT W6
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-2033
Mailing Address - Country:US
Mailing Address - Phone:954-825-9922
Mailing Address - Fax:
Practice Address - Street 1:433 PLAZA REAL STE 275
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-3999
Practice Address - Country:US
Practice Address - Phone:305-632-8577
Practice Address - Fax:786-329-6452
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019419900Medicaid