Provider Demographics
NPI:1972117521
Name:THE BRAIN CLINIC, LLC
Entity Type:Organization
Organization Name:THE BRAIN CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:KRISTEN
Authorized Official - Last Name:BOAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:630-649-2819
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-01
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Single Specialty