Healthcare Provider Details

I. General information

NPI: 1871253989
Provider Name (Legal Business Name): DESTINEE BOHANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24328 VERMONT AVE STE 318
HARBOR CITY CA
90710-2314
US

IV. Provider business mailing address

4255 7TH AVE
LOS ANGELES CA
90008-4704
US

V. Phone/Fax

Practice location:
  • Phone: 424-250-9615
  • Fax:
Mailing address:
  • Phone: 323-823-0517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number42015
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: