Provider Demographics
NPI:1043784234
Name:BOONE, KELLY COLLEEN (MFTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:COLLEEN
Last Name:BOONE
Suffix:
Gender:F
Credentials:MFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 STATE FARM RD STE 304
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-4914
Mailing Address - Country:US
Mailing Address - Phone:561-373-0852
Mailing Address - Fax:
Practice Address - Street 1:805 STATE FARM RD STE 304
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4914
Practice Address - Country:US
Practice Address - Phone:561-373-0852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2094106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist