Provider Demographics
NPI:1104969237
Name:BOUGHTON, CRAIG F (PSYD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:F
Last Name:BOUGHTON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 W BROADMOOR ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-3190
Mailing Address - Country:US
Mailing Address - Phone:417-844-9119
Mailing Address - Fax:
Practice Address - Street 1:440 S MARKET AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2026
Practice Address - Country:US
Practice Address - Phone:417-844-9119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2719101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494634827Medicaid