Provider Demographics
NPI:1669509121
Name:ADDISON BONEY, SAMYRA
Entity type:Individual
Prefix:
First Name:SAMYRA
Middle Name:
Last Name:ADDISON BONEY
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 1:715 ALMOND ST STE A
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-3121
Mailing Address - Country:US
Mailing Address - Phone:352-241-4187
Mailing Address - Fax:352-241-4684
Practice Address - Street 1:715 ALMOND ST
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-3121
Practice Address - Country:US
Practice Address - Phone:352-241-4187
Practice Address - Fax:352-241-4684
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL756701400Medicaid
FL003054400Medicaid