Healthcare Provider Details

I. General information

NPI: 1730241126
Provider Name (Legal Business Name): LAURA KATHLEEN BOUGHTON MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5729 CHURCH ST
MORTON GROVE IL
60053-2511
US

IV. Provider business mailing address

5729 CHURCH ST
MORTON GROVE IL
60053-2511
US

V. Phone/Fax

Practice location:
  • Phone: 847-581-9971
  • Fax: 847-470-0534
Mailing address:
  • Phone: 847-581-9971
  • Fax: 847-470-0534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: