Provider Demographics
NPI:1912114356
Name:BOONE, JAMES RICHARDSON (PH D)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:RICHARDSON
Last Name:BOONE
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 KEYSTONE RD
Mailing Address - Street 2:SUITE A-3
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34688-7436
Mailing Address - Country:US
Mailing Address - Phone:727-944-4600
Mailing Address - Fax:727-945-9800
Practice Address - Street 1:2625 KEYSTONE RD
Practice Address - Street 2:SUITE A-3
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34688-7436
Practice Address - Country:US
Practice Address - Phone:727-944-4600
Practice Address - Fax:727-945-9800
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY04361103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73701BMedicare PIN