Healthcare Provider Details

I. General information

NPI: 1073090122
Provider Name (Legal Business Name): RANDALL D BOEN MS, CRC, LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2018
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204A SOUTH ST
ANNA IL
62906-1549
US

IV. Provider business mailing address

204 SOUTH ST
ANNA IL
62906-1549
US

V. Phone/Fax

Practice location:
  • Phone: 618-833-0599
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.011527
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: