Provider Demographics
NPI:1306207022
Name:BOHN, MELODY
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:BOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8011 AMY HEWES DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-4605
Mailing Address - Country:US
Mailing Address - Phone:478-808-6145
Mailing Address - Fax:
Practice Address - Street 1:8011 AMY HEWES DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-4605
Practice Address - Country:US
Practice Address - Phone:478-808-6145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARBT-18-59681106S00000X
KST-04459224Z00000X
LAL-487103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant