Provider Demographics
NPI:1447724737
Name:BOEHMER, DANIEL P (LCPC)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:P
Last Name:BOEHMER
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14687 N LOST LAKE LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-8097
Mailing Address - Country:US
Mailing Address - Phone:618-214-5463
Mailing Address - Fax:
Practice Address - Street 1:107 SHILOH DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-7301
Practice Address - Country:US
Practice Address - Phone:618-242-6944
Practice Address - Fax:618-242-6726
Is Sole Proprietor?:No
Enumeration Date:2019-01-20
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.004913101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional