Provider Demographics
NPI:1770727356
Name:BOONE, MICHAEL COOPER (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:COOPER
Last Name:BOONE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:JOHN
Other - Last Name:SCHROEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:5110 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-3424
Mailing Address - Country:US
Mailing Address - Phone:800-275-3243
Mailing Address - Fax:718-854-8308
Practice Address - Street 1:5110 12TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-3424
Practice Address - Country:US
Practice Address - Phone:800-275-3243
Practice Address - Fax:718-854-8308
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013140-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical