Provider Demographics
NPI:1386343150
Name:KONICOFF, BENI ELIZABETH
Entity type:Individual
Prefix:
First Name:BENI
Middle Name:ELIZABETH
Last Name:KONICOFF
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 1:500 SE 23RD AVE # 2
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-6020
Mailing Address - Country:US
Mailing Address - Phone:754-234-2131
Mailing Address - Fax:
Practice Address - Street 1:3836 W HILLSBORO BLVD
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-9413
Practice Address - Country:US
Practice Address - Phone:954-421-2355
Practice Address - Fax:954-421-6455
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA77264225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist