Provider Demographics
NPI:1154629947
Name:BOOTH, ANGELA SMALL (MFT)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:SMALL
Last Name:BOOTH
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:RAE
Other - Last Name:SMALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT INTERN
Mailing Address - Street 1:143 FIGUEROA ST STE 14
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-2756
Mailing Address - Country:US
Mailing Address - Phone:805-765-5413
Mailing Address - Fax:
Practice Address - Street 1:143 FIGUEROA ST STE 14
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001-2756
Practice Address - Country:US
Practice Address - Phone:805-765-5413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87421106H00000X
225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist