Basic Information
| Provider Information | |||||||||
| NPI: | 1487054078 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDOUGALD | ||||||||
| FirstName: | BAMBI | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS, RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10140 CENTURION PKWY N | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322560532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046974000 | ||||||||
| FaxNumber: | 9046975102 | ||||||||
| Practice Location | |||||||||
| Address1: | 13535 NEMOURS PKWY | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328277402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075674000 | ||||||||
| FaxNumber: | 4075675924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2014 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 106S00000X | RBT-19-101167 | FL | Y |
No ID Information.