Provider Demographics
NPI:1912575184
Name:BOONE, MICKEY SCOTT
Entity Type:Individual
Prefix:
First Name:MICKEY
Middle Name:SCOTT
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 1:1305 CUMBERLAND AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1343
Mailing Address - Country:US
Mailing Address - Phone:765-464-2991
Mailing Address - Fax:765-436-5509
Practice Address - Street 1:1305 CUMBERLAND AVE STE 110
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1316
Practice Address - Country:US
Practice Address - Phone:765-464-2991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator