Provider Demographics
NPI:1881120061
Name:BOONE, KISHORE
Entity type:Individual
Prefix:
First Name:KISHORE
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 1:3253 CALUMET DR
Mailing Address - Street 2:APT N
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-2955
Mailing Address - Country:US
Mailing Address - Phone:252-676-5326
Mailing Address - Fax:
Practice Address - Street 1:3253 CALUMET DR
Practice Address - Street 2:APT N
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-2955
Practice Address - Country:US
Practice Address - Phone:252-676-5326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
NCP0131941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional