Provider Demographics
NPI:1992477731
Name:BENREY-BOGUSLAVSKY, DORIS
Entity type:Individual
Prefix:MS
First Name:DORIS
Middle Name:
Last Name:BENREY-BOGUSLAVSKY
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 1:165 WELLS RD STE 203
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-3036
Mailing Address - Country:US
Mailing Address - Phone:904-269-3522
Mailing Address - Fax:904-621-9339
Practice Address - Street 1:165 WELLS RD STE 203
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-3036
Practice Address - Country:US
Practice Address - Phone:904-269-3522
Practice Address - Fax:904-621-9339
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLIMH21526101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist