Provider Demographics
NPI:1457589467
Name:BOONE, IRVING (PHD)
Entity Type:Individual
Prefix:DR
First Name:IRVING
Middle Name:
Last Name:BOONE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 LAWSON AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-3328
Mailing Address - Country:US
Mailing Address - Phone:651-216-5774
Mailing Address - Fax:651-645-1688
Practice Address - Street 1:1010 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4746
Practice Address - Country:US
Practice Address - Phone:651-659-0359
Practice Address - Fax:651-645-1688
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300575101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)