Healthcare Provider Details

I. General information

NPI: 1306611405
Provider Name (Legal Business Name): CLIFTON R BOONE JR. LSW, CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3053 W FRANKLIN BLVD
CHICAGO IL
60612-1000
US

IV. Provider business mailing address

2720 S RIVER RD STE 246
DES PLAINES IL
60018-4111
US

V. Phone/Fax

Practice location:
  • Phone: 773-475-6703
  • Fax: 773-475-6745
Mailing address:
  • Phone: 847-306-7277
  • Fax: 847-306-7278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4168617
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: