Healthcare Provider Details

I. General information

NPI: 1861411589
Provider Name (Legal Business Name): KIMBERLY BOONE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 GROVE RD STE C
MIDLOTHIAN VA
23114-2666
US

IV. Provider business mailing address

831 GROVE RD STE C
MIDLOTHIAN VA
23114-2666
US

V. Phone/Fax

Practice location:
  • Phone: 804-743-0960
  • Fax:
Mailing address:
  • Phone: 804-743-0960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0904004211
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904004211
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: