Provider Demographics
NPI:1225294085
Name:HANSON BOOTHE, NIKOL L (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NIKOL
Middle Name:L
Last Name:HANSON BOOTHE
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3919 E WALLER LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4914
Mailing Address - Country:US
Mailing Address - Phone:480-584-3923
Mailing Address - Fax:
Practice Address - Street 1:15640 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-3512
Practice Address - Country:US
Practice Address - Phone:602-439-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1740235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist