MEDICARE: MR. BONAVENTURAS MICHAEL VYZAS LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH0001886	FL

General Provider Information

NPI Number	:	1306823380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BONAVENTURAS MICHAEL VYZAS LMHC

Provider Business Mailing Address
First Line	:	16544 N DALE MABRY HWY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-1325
Country	:	US
Telephone Number	:	813-960-8622
Fax Number	:	813-960-1554

Provider Business Practice Location Address
First Line	:	16544 N DALE MABRY HWY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-1325
Country	:	US
Telephone Number	:	813-960-8622
Fax Number	:	813-960-1554

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	07/08/2007

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