Provider Demographics
NPI:1184205346
Name:BOONE, MAKYLA LYNN
Entity Type:Individual
Prefix:
First Name:MAKYLA
Middle Name:LYNN
Last Name:BOONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:LYNN
Other - Last Name:BOONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:232 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3609
Mailing Address - Country:US
Mailing Address - Phone:503-294-1681
Mailing Address - Fax:
Practice Address - Street 1:33 NW BROADWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3580
Practice Address - Country:US
Practice Address - Phone:503-228-7134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20-QMHA-R-0810101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health