Healthcare Provider Details

I. General information

NPI: 1174879696
Provider Name (Legal Business Name): MICHANNE E BOHANON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 W SHAW AVE STE 101
FRESNO CA
93711-3216
US

IV. Provider business mailing address

3434 W SHAW AVE STE 101
FRESNO CA
93711-3216
US

V. Phone/Fax

Practice location:
  • Phone: 559-275-1784
  • Fax:
Mailing address:
  • Phone: 559-275-1784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: