Healthcare Provider Details

I. General information

NPI: 1417861386
Provider Name (Legal Business Name): BOONEVILLE WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 W COLLEGE ST
BOONEVILLE MS
38829-3411
US

IV. Provider business mailing address

457 COUNTY ROAD 5011
BOONEVILLE MS
38829-9430
US

V. Phone/Fax

Practice location:
  • Phone: 662-416-6204
  • Fax:
Mailing address:
  • Phone: 662-416-6204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: DANA STEPHENS
Title or Position: OWNER
Credential:
Phone: 662-416-6204