Provider Demographics
NPI:1649860065
Name:BOONE, KENNEDI (BCBA)
Entity type:Individual
Prefix:
First Name:KENNEDI
Middle Name:
Last Name:BOONE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HALLORAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST. CLAIRSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43950
Mailing Address - Country:US
Mailing Address - Phone:740-269-5743
Mailing Address - Fax:
Practice Address - Street 1:2475 W CHICAGO ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2467
Practice Address - Country:US
Practice Address - Phone:605-206-5004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-21-152267106S00000X
OH1-24-72827103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician