MEDICARE: ANTHONY DWIGHT BOBO, SR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist

General Provider Information

NPI Number	:	1881341857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTHONY DWIGHT BOBO, SR

Provider Business Mailing Address
First Line	:	7501 OKEECHOBEE CT
Second Line	:
City	:	TEMPLE TERR
State	:	FL
Zip	:	33637-7345
Country	:	US
Telephone Number	:	330-573-4722
Fax Number	:

Provider Business Practice Location Address
First Line	:	7501 OKEECHOBEE CT
Second Line	:
City	:	TEMPLE TERR
State	:	FL
Zip	:	33637-7345
Country	:	US
Telephone Number	:	330-573-4722
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ANTHONY DWIGHT BOBO SR.
Credential	:	PH.D.
Telephone Number	:	133-057-3472

Provider Enumeration Date	:	03/09/2022
Last Update Date	:	03/09/2022

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