Provider Demographics
NPI:1679036529
Name:BOONE, SYREETA V
Entity Type:Individual
Prefix:MRS
First Name:SYREETA
Middle Name:V
Last Name:BOONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14001 WESTMEATH DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-6909
Mailing Address - Country:US
Mailing Address - Phone:443-271-1453
Mailing Address - Fax:
Practice Address - Street 1:10605 CONCORD ST STE 207
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2526
Practice Address - Country:US
Practice Address - Phone:301-231-9001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC1734101YA0400X
MD186761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1033231204Medicaid
MD1033231204OtherCAREFIRST