Provider Demographics
NPI:1922194034
Name:BOONE, GLENN PAUL (MDIV)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:PAUL
Last Name:BOONE
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 BURNET RD STE 320
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-1268
Mailing Address - Country:US
Mailing Address - Phone:512-451-8818
Mailing Address - Fax:512-452-0295
Practice Address - Street 1:7600 BURNET RD STE 320
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-1268
Practice Address - Country:US
Practice Address - Phone:512-451-8818
Practice Address - Fax:512-452-0295
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3157101YA0400X
TX11288101YP2500X
NC2139101YP2500X
LA2075101YP2500X
TX2683-002737106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3157OtherLCDC LICENSE
TX11288OtherLPC LICENSE
TX2683-002737OtherLMFT LICENSE