Provider Demographics
NPI:1962841395
Name:BOUGHTON, SETH WILLIAM (MSW)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:WILLIAM
Last Name:BOUGHTON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 AVENUE C
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-5410
Mailing Address - Country:US
Mailing Address - Phone:217-442-3200
Mailing Address - Fax:217-442-7460
Practice Address - Street 1:501 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-8630
Practice Address - Country:US
Practice Address - Phone:217-351-9744
Practice Address - Fax:217-351-9746
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker