Healthcare Provider Details

I. General information

NPI: 1134314628
Provider Name (Legal Business Name): PETALS CATRECE RAINEY-BOONE MS, ED.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2007
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 UJAMAA DR
RALEIGH NC
27610-5773
US

IV. Provider business mailing address

1317 UJAMAA DR
RALEIGH NC
27610-5773
US

V. Phone/Fax

Practice location:
  • Phone: 919-755-3396
  • Fax:
Mailing address:
  • Phone: 919-755-3396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2318
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: