=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417861386
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOONEVILLE WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2026
-----------------------------------------------------
Last Update Date | 09/29/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 221 W COLLEGE ST
-----------------------------------------------------
City | BOONEVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38829-3411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-416-6204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 457 COUNTY ROAD 5011
-----------------------------------------------------
City | BOONEVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38829-9430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-416-6204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANA STEPHENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-416-6204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------