Healthcare Provider Details

I. General information

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

Provider Other Name: BONNY GLOMARIX FRESCURA GUTIERREZ LMFT

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 TRELLIS BAY DR
SAINT AUGUSTINE FL
32092-3231
US

IV. Provider business mailing address

841 TRELLIS BAY DR
SAINT AUGUSTINE FL
32092-3231
US

V. Phone/Fax

Practice location:
  • Phone: 908-509-1248
  • Fax:
Mailing address:
  • Phone: 904-417-3519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT5288
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: