Healthcare Provider Details

I. General information

NPI: 1780210856
Provider Name (Legal Business Name): BONNY FRESCURA MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 KINGSLEY AVE STE 136
ORANGE PARK FL
32073-4547
US

IV. Provider business mailing address

13444 GRAN BAY PKWY
JACKSONVILLE FL
32258-6491
US

V. Phone/Fax

Practice location:
  • Phone: 904-214-3222
  • Fax:
Mailing address:
  • Phone: 904-417-3519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number37FA00007200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: