Provider Demographics
NPI:1750050605
Name:BOHANNON, MATTHEW PAUL (CRSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PAUL
Last Name:BOHANNON
Suffix:
Gender:M
Credentials:CRSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10019 REISTERSTOWN RD FL 3
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-3902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 CHENELL DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-8525
Practice Address - Country:US
Practice Address - Phone:603-232-9099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0355101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)