Provider Demographics
NPI:1124036702
Name:BOHANON, LEONARD M (PHD)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:M
Last Name:BOHANON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PINE MANOR DR
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE NORTH
Mailing Address - State:TX
Mailing Address - Zip Code:77385-9059
Mailing Address - Country:US
Mailing Address - Phone:832-628-5253
Mailing Address - Fax:
Practice Address - Street 1:101 PINE MANOR DR
Practice Address - Street 2:
Practice Address - City:OAK RIDGE NORTH
Practice Address - State:TX
Practice Address - Zip Code:77385-9059
Practice Address - Country:US
Practice Address - Phone:832-628-5253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-2536103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
138628OtherVALUE OPTIONS
48145516OtherWAUSAU
TX030445301Medicaid
225505OtherCOMPSYCH
TX0015DLOtherBLUE CROSS/BLUE SHIELD
225505OtherCOMPSYCH