Healthcare Provider Details

I. General information

NPI: 1083803092
Provider Name (Legal Business Name): DESEREE DEANN BOHANAN MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 08/17/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 LONG BEACH BLVD
LONG BEACH CA
90807-2616
US

IV. Provider business mailing address

1313 COLGATE DR
DAVIS CA
95616-3904
US

V. Phone/Fax

Practice location:
  • Phone: 510-226-6180
  • Fax:
Mailing address:
  • Phone: 310-272-6193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: