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Individual

RICHARD MICHAEL BOHANNAN

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
LCSW

Contact information

Practice address
650 E INDIAN SCHOOL RD, PHOENIX, AZ 85012-1839
(623) 521-7174
Mailing address
7067 W PALMAIRE AVE, GLENDALE, AZ 85303-2640
(623) 521-7174

Taxonomy

Speciality
Code
Description
License number
State
104100000X
Social Worker
LMSW-13380
AZ
1041C0700X
Clinical Social Worker
Primary
LCSW-15674
AZ

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
073274
AZ
Enumeration date
07/17/2012
Last updated
12/11/2015
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