Provider Demographics
NPI:1285180182
Name:BOBO, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BOBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:
Other - Last Name:BOBO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:3511 HIGHWAY 67 W
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:AR
Mailing Address - Zip Code:71801-8858
Mailing Address - Country:US
Mailing Address - Phone:870-703-1755
Mailing Address - Fax:
Practice Address - Street 1:3511 HIGHWAY 67 W
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801-8858
Practice Address - Country:US
Practice Address - Phone:870-703-1755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1193245222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist