Provider Demographics
NPI:1386239853
Name:BOHNAK, MICHELLE
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:BOHNAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1343 KROEGER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63135-2233
Mailing Address - Country:US
Mailing Address - Phone:314-605-8026
Mailing Address - Fax:
Practice Address - Street 1:12110 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2599
Practice Address - Country:US
Practice Address - Phone:314-605-8026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103K00000X
MO2021009167103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst