Provider Demographics
NPI:1700492592
Name:STIGLETS, BLAINE (RBT)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:
Last Name:STIGLETS
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-4624
Mailing Address - Country:US
Mailing Address - Phone:228-380-0355
Mailing Address - Fax:
Practice Address - Street 1:15489 DEDEAUX RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2667
Practice Address - Country:US
Practice Address - Phone:228-357-5671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRBT-20-134263106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician