Provider Demographics
NPI:1558718528
Name:BOONE, DERRICK (PSYD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:BOONE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E 25TH ST APT 1FW
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-3182
Mailing Address - Country:US
Mailing Address - Phone:443-745-7729
Mailing Address - Fax:
Practice Address - Street 1:210 E 25TH ST APT 1FW
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-3182
Practice Address - Country:US
Practice Address - Phone:443-745-7729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9014616103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical