Provider Demographics
NPI:1730458548
Name:BOHANNAN, SHERRY DENISE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SHERRY
Middle Name:DENISE
Last Name:BOHANNAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 SE 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1717
Mailing Address - Country:US
Mailing Address - Phone:503-499-5200
Mailing Address - Fax:
Practice Address - Street 1:2701 NW VAUGHN ST STE 140
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5344
Practice Address - Country:US
Practice Address - Phone:503-499-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR387007OtherKAISER PERMANENTE