Provider Demographics
NPI:1093551350
Name:BLUE BOLT PEDIATRIC CARE
Entity type:Organization
Organization Name:BLUE BOLT PEDIATRIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CERTIFIED BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROBEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS ED, BCBA
Authorized Official - Phone:917-580-2599
Mailing Address - Street 1:1555 SHERMAN AVE # 324
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 ELGIN RD APT 1218
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-5628
Practice Address - Country:US
Practice Address - Phone:917-580-2599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-06
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty