Provider Demographics
NPI:1235522681
Name:MORAVECKY, BONNIE
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:MORAVECKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 PEMBROKE AVE NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1309
Mailing Address - Country:US
Mailing Address - Phone:321-693-1095
Mailing Address - Fax:
Practice Address - Street 1:1060 PEMBROKE AVE NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1309
Practice Address - Country:US
Practice Address - Phone:321-693-1095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health