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General NPI Number Information
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NPI Number | 1972117521
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Entity Type | Organization
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Legal Business Name | THE BRAIN CLINIC, LLC
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Dates
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Enumeration Date | 09/01/2020
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Last Update Date | 12/07/2020
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Provider Practice Location Address
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Address Line | 417 N MAIN ST
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City | SANDWICH
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State | IL
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Zip | 60548-1569
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Country | US
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Telephone | 630-649-2819
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Fax |
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Provider Business Mailing Address
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Address Line | 417 N MAIN ST
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City | SANDWICH
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State | IL
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Zip | 60548-1569
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Country | US
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Telephone | 630-649-2819
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. BRANDI KRISTEN BOAN
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Credential | PSYD
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Telephone | 630-649-2819
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TP0016X
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Taxonomy Name | Prescribing (Medical) Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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