Provider Demographics
NPI:1598898207
Name:BOHANON, TYNESHIA
Entity Type:Individual
Prefix:
First Name:TYNESHIA
Middle Name:
Last Name:BOHANON
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 1:2809 FOREST HOME RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5320
Mailing Address - Country:US
Mailing Address - Phone:866-972-1268
Mailing Address - Fax:
Practice Address - Street 1:4001 COMMERCIAL CENTER DR STE 2
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-9616
Practice Address - Country:US
Practice Address - Phone:870-732-7920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3273-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR182339795Medicaid