Provider Demographics
NPI:1679762496
Name:BOONE, MICHAEL DAVID (OTR/L)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:BOONE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 NE 139TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-8705
Mailing Address - Country:US
Mailing Address - Phone:405-396-2119
Mailing Address - Fax:
Practice Address - Street 1:8201 NE 139TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8705
Practice Address - Country:US
Practice Address - Phone:405-396-2119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOT713225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOT713OtherOK LICENSE BOARD