Provider Demographics
NPI:1780862219
Name:BOAN, BRANDI KRISTEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRANDI
Middle Name:KRISTEN
Last Name:BOAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-1569
Mailing Address - Country:US
Mailing Address - Phone:630-649-2819
Mailing Address - Fax:
Practice Address - Street 1:417 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-1569
Practice Address - Country:US
Practice Address - Phone:630-649-2819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
IL074000002103TP0016X
IL180.007281101YP2500X
IL071008926103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional