Provider Demographics
NPI:1275659138
Name:BOEHLER, LARRY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:L
Last Name:BOEHLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 367
Mailing Address - Street 2:
Mailing Address - City:MULBERRY GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:62262-9315
Mailing Address - Country:US
Mailing Address - Phone:618-326-8824
Mailing Address - Fax:
Practice Address - Street 1:217 SUPPIGER LN
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1132
Practice Address - Country:US
Practice Address - Phone:618-654-1405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional