Healthcare Provider Details

I. General information

NPI: 1538139902
Provider Name (Legal Business Name): MARTIN LEWIS BOONE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 COOMBS FARM DRIVE SUITE 202
MORGANTOWN WV
26508
US

IV. Provider business mailing address

9000 COOMBS FARM DRIVE SUITE 202
MORGANTOWN WV
26508
US

V. Phone/Fax

Practice location:
  • Phone: 304-554-0504
  • Fax: 304-554-0505
Mailing address:
  • Phone: 304-554-0504
  • Fax: 304-554-0505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number616
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: