Provider Demographics
NPI:1073090122
Name:BOEN, RANDALL D (MS, CRC, LCPC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:D
Last Name:BOEN
Suffix:
Gender:M
Credentials:MS, CRC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204A SOUTH ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1549
Practice Address - Country:US
Practice Address - Phone:618-833-0599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-22
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225C00000X
IL180.011527101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor