Healthcare Provider Details

I. General information

NPI: 1396874814
Provider Name (Legal Business Name): REINA BOONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1228 FAIRMONT DR # 705
SAN LEANDRO CA
94578-3508
US

IV. Provider business mailing address

1228 FAIRMONT DR # 705
SAN LEANDRO CA
94578-3508
US

V. Phone/Fax

Practice location:
  • Phone: 510-401-7511
  • Fax:
Mailing address:
  • Phone: 510-401-7511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPSB94028103
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberPSB94028103
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: