Provider Demographics
NPI:1144393778
Name:EDGE-BOOTH, HOLLY LEIGH (PHD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:LEIGH
Last Name:EDGE-BOOTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E DEL MAR BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2544
Mailing Address - Country:US
Mailing Address - Phone:626-818-2748
Mailing Address - Fax:
Practice Address - Street 1:200 E DEL MAR BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2544
Practice Address - Country:US
Practice Address - Phone:626-818-2748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20955103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist