MEDICARE: MELINDA ABBYGAIL BOOY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1467090928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELINDA ABBYGAIL BOOY

Provider Business Mailing Address
First Line	:	5299 WILHELM RD NW
Second Line	:
City	:	RAPID CITY
State	:	MI
Zip	:	49676-9518
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5299 WILHELM RD NW
Second Line	:
City	:	RAPID CITY
State	:	MI
Zip	:	49676-9518
Country	:	US
Telephone Number	:	989-348-8522
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2019
Last Update Date	:	05/21/2020

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