Provider Demographics
NPI:1578077624
Name:BOONE, DERRICK KELVIN
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:KELVIN
Last Name:BOONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6153 SOUTH FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:CHATAIGNIER
Mailing Address - State:LA
Mailing Address - Zip Code:70524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6153 SOUTH FIRST STREET
Practice Address - Street 2:
Practice Address - City:CHATAIGNIER
Practice Address - State:LA
Practice Address - Zip Code:70524
Practice Address - Country:US
Practice Address - Phone:337-580-4144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-28
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator