Provider Demographics
NPI:1760671218
Name:BOHANNON, ANDREA R (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:R
Last Name:BOHANNON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:MISS
Other - First Name:ANDREA
Other - Middle Name:R
Other - Last Name:RICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, PLPC
Mailing Address - Street 1:330 N GORE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-1600
Mailing Address - Country:US
Mailing Address - Phone:314-919-4700
Mailing Address - Fax:
Practice Address - Street 1:330 N GORE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119
Practice Address - Country:US
Practice Address - Phone:314-919-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOL2040520201041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool