Provider Demographics
NPI:1205444601
Name:BOONE, CARL NATHANIEL
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:NATHANIEL
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 1:2031 BROOKS DR APT 713
Mailing Address - Street 2:
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20747-1009
Mailing Address - Country:US
Mailing Address - Phone:240-370-2454
Mailing Address - Fax:202-832-3454
Practice Address - Street 1:4414 3RD ST SE # EB
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-3229
Practice Address - Country:US
Practice Address - Phone:240-370-2454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC1177101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)