Provider Demographics
NPI:1407503592
Name:VANDEN BOOGART, BREANNA LYNN (LPC)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:LYNN
Last Name:VANDEN BOOGART
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9659 BRYAN PL
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7472
Mailing Address - Country:US
Mailing Address - Phone:708-822-2467
Mailing Address - Fax:
Practice Address - Street 1:6713 KINGERY HWY
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5142
Practice Address - Country:US
Practice Address - Phone:773-234-0423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015433101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health