Provider Demographics
NPI:1083923783
Name:BOHANNAN, AMY L (BCBA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:BOHANNAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6253 KARSTON DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301-8737
Mailing Address - Country:US
Mailing Address - Phone:651-341-1858
Mailing Address - Fax:
Practice Address - Street 1:6253 KARSTON DR NE
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55301-8737
Practice Address - Country:US
Practice Address - Phone:651-341-1858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1-08-4872103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst