Provider Demographics
NPI:1184661175
Name:BOOTH, RAYDELL (PHD)
Entity Type:Individual
Prefix:
First Name:RAYDELL
Middle Name:
Last Name:BOOTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13945 W WAINWRIGHT DR #106
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1925
Mailing Address - Country:US
Mailing Address - Phone:208-377-1131
Mailing Address - Fax:208-377-1171
Practice Address - Street 1:4060 E CHINDEN BLVD
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6481
Practice Address - Country:US
Practice Address - Phone:208-377-1131
Practice Address - Fax:208-377-1171
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY211103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDR60143Medicare UPIN
ID1680673Medicare ID - Type Unspecified