Provider Demographics
NPI:1407687528
Name:BJORNSON, THEODORE LOUIS
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:LOUIS
Last Name:BJORNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6930 WINTERBERRY CT
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE HEIGHTS
Mailing Address - State:FL
Mailing Address - Zip Code:32656-8672
Mailing Address - Country:US
Mailing Address - Phone:408-713-8195
Mailing Address - Fax:
Practice Address - Street 1:782 FOXRIDGE CENTER DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-5776
Practice Address - Country:US
Practice Address - Phone:904-637-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-10
Last Update Date:2024-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-368251106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician