Provider Demographics
NPI:1912469131
Name:BOLT, EMILY ROSE (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ROSE
Last Name:BOLT
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ROSE
Other - Last Name:DUNCAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, BCBA
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:
Mailing Address - Fax:
Practice Address - Street 1:4000 SMITHTOWN RD STE 200
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6560
Practice Address - Country:US
Practice Address - Phone:470-632-4990
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
GA1-19-35273103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst