Provider Demographics
NPI:1073919353
Name:BOHN, BEVERLY (MED)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:BOHN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 DOVE CT
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-4414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 DOVE CT
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34759-4414
Practice Address - Country:US
Practice Address - Phone:484-602-4807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
PA101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool