Provider Demographics
NPI:1114687050
Name:BOOTH, TAYLOR AUTUMN
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:AUTUMN
Last Name:BOOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 LYNDALE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-3021
Mailing Address - Country:US
Mailing Address - Phone:507-766-6218
Mailing Address - Fax:
Practice Address - Street 1:909 CENTER ST
Practice Address - Street 2:
Practice Address - City:NEW ULM
Practice Address - State:MN
Practice Address - Zip Code:56073-3251
Practice Address - Country:US
Practice Address - Phone:507-766-6218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician