Provider Demographics
NPI:1134314628
Name:RAINEY-BOONE, PETALS CATRECE (MS, EDS)
Entity Type:Individual
Prefix:
First Name:PETALS
Middle Name:CATRECE
Last Name:RAINEY-BOONE
Suffix:
Gender:F
Credentials:MS, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 UJAMAA DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-5773
Mailing Address - Country:US
Mailing Address - Phone:919-755-3396
Mailing Address - Fax:
Practice Address - Street 1:1317 UJAMAA DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-5773
Practice Address - Country:US
Practice Address - Phone:919-755-3396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-08
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2318103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107568Medicaid