Provider Demographics
NPI:1255772125
Name:ORTMAN, BLAIR NICHOLE (BCBA)
Entity type:Individual
Prefix:MISS
First Name:BLAIR
Middle Name:NICHOLE
Last Name:ORTMAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:BLAIR
Other - Middle Name:NICHOLE
Other - Last Name:JACOBSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:185-583-2672
Mailing Address - Fax:
Practice Address - Street 1:1413 TECH BLVD STE 122
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-7822
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-13-5479103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst