Provider Demographics
NPI:1124036702
Name:BOHANON, LEONARD M (PHD)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:M
Last Name:BOHANON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 TIMBERLOCH PL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-1150
Mailing Address - Country:US
Mailing Address - Phone:832-628-5253
Mailing Address - Fax:281-727-0428
Practice Address - Street 1:2203 TIMBERLOCH PL
Practice Address - Street 2:SUITE 100
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-1103
Practice Address - Country:US
Practice Address - Phone:832-628-5253
Practice Address - Fax:281-727-0428
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-2536103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
138628OtherVALUE OPTIONS
48145516OtherWAUSAU
TX030445301Medicaid
225505OtherCOMPSYCH
TX0015DLOtherBLUE CROSS/BLUE SHIELD
225505OtherCOMPSYCH