Provider Demographics
NPI:1831296649
Name:BOHM, KENNETH H (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:H
Last Name:BOHM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8515 DELMAR BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-2168
Mailing Address - Country:US
Mailing Address - Phone:314-567-1044
Mailing Address - Fax:314-567-1060
Practice Address - Street 1:8515 DELMAR BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-2168
Practice Address - Country:US
Practice Address - Phone:314-567-1044
Practice Address - Fax:314-567-1060
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00017103TA0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
339528OtherBJC BEHAVIORAL HEALTH