Provider Demographics
NPI:1205245917
Name:BOONE, DEVON
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:
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 1:3427 4TH AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4910
Mailing Address - Country:US
Mailing Address - Phone:619-525-9903
Mailing Address - Fax:619-525-9908
Practice Address - Street 1:3427 4TH AVE FL 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4910
Practice Address - Country:US
Practice Address - Phone:619-525-9903
Practice Address - Fax:619-525-9908
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 104100000X
CA72191104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator