Provider Demographics
NPI:1831488964
Name:BOHANNA, ROBERT LEE (AS)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEE
Last Name:BOHANNA
Suffix:
Gender:M
Credentials:AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 N SONORA AVE
Mailing Address - Street 2:SUITE 113
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-3966
Mailing Address - Country:US
Mailing Address - Phone:559-276-7558
Mailing Address - Fax:559-276-7568
Practice Address - Street 1:4705 N SONORA AVE
Practice Address - Street 2:SUITE 113
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-3966
Practice Address - Country:US
Practice Address - Phone:559-276-7558
Practice Address - Fax:559-276-7568
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC6273384OtherDRIVER LICENSE