Provider Demographics
NPI:1366250508
Name:BOUGHTON PRICE, LETICIA
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:BOUGHTON PRICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11033 S STATE ST UNIT 286126
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-4379
Mailing Address - Country:US
Mailing Address - Phone:773-317-5571
Mailing Address - Fax:
Practice Address - Street 1:10331 S FOREST AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-2816
Practice Address - Country:US
Practice Address - Phone:773-317-5571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0270761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical