Provider Demographics
NPI:1811127749
Name:BOHANNON, EDNA JEANNENE (PHD, MFT)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:JEANNENE
Last Name:BOHANNON
Suffix:
Gender:F
Credentials:PHD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 - COLLIER DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577
Mailing Address - Country:US
Mailing Address - Phone:510-351-5271
Mailing Address - Fax:510-351-4378
Practice Address - Street 1:5299 - COLLEGE AVE.
Practice Address - Street 2:SUITE 6
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618
Practice Address - Country:US
Practice Address - Phone:510-351-5271
Practice Address - Fax:510-351-4378
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC.21208106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist