Healthcare Provider Details

I. General information

NPI: 1083923783
Provider Name (Legal Business Name): AMY L BOHANNAN BCBA,LBA, LPC-MHSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 MALABAR DR
GERMANTOWN TN
38138-3025
US

IV. Provider business mailing address

1910 MALABAR DR
GERMANTOWN TN
38138-3025
US

V. Phone/Fax

Practice location:
  • Phone: 651-341-1858
  • Fax:
Mailing address:
  • Phone: 651-341-1858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6896
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-08-4872
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number051
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: