Provider Demographics
NPI:1700304052
Name:BENGZON, MICHELLE MOSQUEDA
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MOSQUEDA
Last Name:BENGZON
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 1:641 5TH AVE APT 28B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-5908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:280 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-0801
Practice Address - Country:US
Practice Address - Phone:917-289-2302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
002373106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator