Healthcare Provider Details

I. General information

NPI: 1639566276
Provider Name (Legal Business Name): ANGELA FAITH BOONE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 SIJEN AVE BLDG 2032
WHITEMAN AFB MO
65305-1269
US

IV. Provider business mailing address

13387 MARTIN RD
LA MONTE MO
65337-2902
US

V. Phone/Fax

Practice location:
  • Phone: 660-233-2903
  • Fax:
Mailing address:
  • Phone: 660-233-2903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2014037634
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2017024101
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: