1740972264 NPI number — MARNITA LYNETTE BOONE MA PSYCHOLOGY

Table of content: MARNITA LYNETTE BOONE MA PSYCHOLOGY (NPI 1740972264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740972264 NPI number — MARNITA LYNETTE BOONE MA PSYCHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOONE
Provider First Name:
MARNITA
Provider Middle Name:
LYNETTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA PSYCHOLOGY
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740972264
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1504 CROCKETT GARDENS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GEORGETOWN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78628-4033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-377-2954
Provider Business Mailing Address Fax Number:
770-377-2954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1504 CROCKETT GARDENS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78628-4033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-377-2954
Provider Business Practice Location Address Fax Number:
770-377-2954
Provider Enumeration Date:
05/23/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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