=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023726122
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA BOONE LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2022
-----------------------------------------------------
Last Update Date | 11/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 MOTTS DR
-----------------------------------------------------
City | SEALE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36875-3910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-855-3695
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2755 WINTERGREEN CT
-----------------------------------------------------
City | PHENIX CITY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36867-7351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-442-1246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------