Provider Demographics
NPI:1679080782
Name:IGIELSKI, BONNIE JO (BCBA)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:JO
Last Name:IGIELSKI
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3357 WELLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-7469
Mailing Address - Country:US
Mailing Address - Phone:610-506-3141
Mailing Address - Fax:
Practice Address - Street 1:5215 DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-5708
Practice Address - Country:US
Practice Address - Phone:850-270-0640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-18-33040103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1871917005Medicaid