Healthcare Provider Details

I. General information

NPI: 1669509121
Provider Name (Legal Business Name): SAMYRA ADDISON BONEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 ALMOND ST
CLERMONT FL
34711-3121
US

IV. Provider business mailing address

715 ALMOND ST STE A
CLERMONT FL
34711-3121
US

V. Phone/Fax

Practice location:
  • Phone: 352-241-4187
  • Fax: 352-241-4684
Mailing address:
  • Phone: 352-241-4187
  • Fax: 352-241-4684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: