Healthcare Provider Details

I. General information

NPI: 1780862219
Provider Name (Legal Business Name): BRANDI KRISTEN BOAN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 N MAIN ST
SANDWICH IL
60548-1569
US

IV. Provider business mailing address

417 N MAIN ST
SANDWICH IL
60548-1569
US

V. Phone/Fax

Practice location:
  • Phone: 630-649-2819
  • Fax:
Mailing address:
  • Phone: 630-649-2819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.007281
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071008926
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number074000002
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: