Healthcare Provider Details

I. General information

NPI: 1770018079
Provider Name (Legal Business Name): MARKUS BOONE CASAC-T
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

556 CLINTON AVE S
ROCHESTER NY
14620-1105
US

IV. Provider business mailing address

361 STONE RD
ROCHESTER NY
14616-4219
US

V. Phone/Fax

Practice location:
  • Phone: 585-442-8422
  • Fax: 585-442-8494
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number32972
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: