Provider Demographics
NPI:1144081407
Name:BOMHARDT, ELIZA
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:
Last Name:BOMHARDT
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 1:1701 MILITARY TRL
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-6330
Mailing Address - Country:US
Mailing Address - Phone:561-242-1725
Mailing Address - Fax:
Practice Address - Street 1:1701 MILITARY TRL
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-6330
Practice Address - Country:US
Practice Address - Phone:561-242-1725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB648084106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician