Basic Information
| Provider Information | |||||||||
| NPI: | 1649760968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULGER | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2104 LEWIS TURNER BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325471316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508623728 | ||||||||
| FaxNumber: | 8508626270 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 RACETRACK RD NW | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325474612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508623728 | ||||||||
| FaxNumber: | 8508626270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2018 | ||||||||
| LastUpdateDate: | 07/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | 18-55199 | FL | N | 103K00000X | 1-21-50416 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | RBT-18-55199 | 01 | FL | REGISTERED BEHAVIOR TECHNICIAN | OTHER |