Provider Demographics
NPI:1881141695
Name:BOONE, BENITA J (MS, CCC)
Entity type:Individual
Prefix:
First Name:BENITA
Middle Name:J
Last Name:BOONE
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 S INDIANAPOLIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-2625
Mailing Address - Country:US
Mailing Address - Phone:918-925-1300
Mailing Address - Fax:918-925-1317
Practice Address - Street 1:447 S INDIANAPOLIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74112-2625
Practice Address - Country:US
Practice Address - Phone:918-925-1300
Practice Address - Fax:918-925-1317
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1024235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist