Provider Demographics
NPI:1144394180
Name:BOOTH, THOMAS C (MA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:C
Last Name:BOOTH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 GATEWAY MALL
Mailing Address - Street 2:#342 GREENTREE COURT
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505-2489
Mailing Address - Country:US
Mailing Address - Phone:402-434-2730
Mailing Address - Fax:
Practice Address - Street 1:210 GATEWAY MALL
Practice Address - Street 2:#342 GREENTREE COURT
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68505-2489
Practice Address - Country:US
Practice Address - Phone:402-434-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE0013101YA0400X
NE2987101YM0800X
NE1547101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE68505A008OtherTRICARE
NE47075636930Medicaid
NE85540OtherBLUE CROSS & BLUE SHIELD
NE47075636930Medicaid