Provider Demographics
NPI:1881341857
Name:ANTHONY DWIGHT BOBO, SR
Entity type:Organization
Organization Name:ANTHONY DWIGHT BOBO, SR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:BOBO
Authorized Official - Suffix:SR
Authorized Official - Credentials:PHD
Authorized Official - Phone:133-057-3472
Mailing Address - Street 1:7501 OKEECHOBEE CT
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERR
Mailing Address - State:FL
Mailing Address - Zip Code:33637-7345
Mailing Address - Country:US
Mailing Address - Phone:330-573-4722
Mailing Address - Fax:
Practice Address - Street 1:7501 OKEECHOBEE CT
Practice Address - Street 2:
Practice Address - City:TEMPLE TERR
Practice Address - State:FL
Practice Address - Zip Code:33637-7345
Practice Address - Country:US
Practice Address - Phone:330-573-4722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty