Provider Demographics
NPI:1538139902
Name:BOONE, MARTIN LEWIS (PHD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:LEWIS
Last Name:BOONE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 COOMBS FARM DRIVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508
Mailing Address - Country:US
Mailing Address - Phone:304-554-0504
Mailing Address - Fax:304-554-0505
Practice Address - Street 1:9000 COOMBS FARM DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508
Practice Address - Country:US
Practice Address - Phone:304-554-0504
Practice Address - Fax:304-554-0505
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV616103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV680012592OtherRAILROAD MEDICARE
WV9201023000Medicaid
WV9201023000Medicaid
WVQ50719E879Medicare PIN
WV680012592OtherRAILROAD MEDICARE