Provider Demographics
NPI:1003275678
Name:BOSH, STEPHANIE CHERYL (MS, MCAP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CHERYL
Last Name:BOSH
Suffix:
Gender:F
Credentials:MS, MCAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 ELLIS RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-3582
Mailing Address - Country:US
Mailing Address - Phone:904-423-0017
Mailing Address - Fax:
Practice Address - Street 1:580 ELLIS RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-3582
Practice Address - Country:US
Practice Address - Phone:904-423-0017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLADC-010765-2015101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor