Basic Information
| Provider Information | |||||||||
| NPI: | 1174770267 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BELL | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS, BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3335 CARTER RD | ||||||||
| Address2: | |||||||||
| City: | MIMS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327545380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217595462 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2073 GARDEN ST | ||||||||
| Address2: | |||||||||
| City: | TITUSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327963243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218883020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2008 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TM1800X | N | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 103K00000X | 1073698 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 017908700 | 05 | FL | MEDICAID |