Healthcare Provider Details

I. General information

NPI: 1013262963
Provider Name (Legal Business Name): RICHARD MICHAEL BOHANNAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 S MCCLINTOCK DR STE 105
TEMPE AZ
85282-2692
US

IV. Provider business mailing address

2120 S MCCLINTOCK DR STE 105
TEMPE AZ
85282-2692
US

V. Phone/Fax

Practice location:
  • Phone: 480-804-0326
  • Fax:
Mailing address:
  • Phone: 480-804-0326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-15674
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-13380
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: