Provider Demographics
NPI:1912475591
Name:BOLERJACK, CAMI LEA (RBT)
Entity Type:Individual
Prefix:
First Name:CAMI
Middle Name:LEA
Last Name:BOLERJACK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11718 SE FEDERAL HWY # 245
Mailing Address - Street 2:
Mailing Address - City:HOBE SOUND
Mailing Address - State:FL
Mailing Address - Zip Code:33455-5303
Mailing Address - Country:US
Mailing Address - Phone:504-669-9099
Mailing Address - Fax:
Practice Address - Street 1:7778 SW JACK JAMES DR
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-7249
Practice Address - Country:US
Practice Address - Phone:504-669-9099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB455926106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician