Provider Demographics
NPI:1225896426
Name:BOOTHE, MICHELLE NICHOLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICHOLE
Last Name:BOOTHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2639 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-2702
Mailing Address - Country:US
Mailing Address - Phone:740-534-3253
Mailing Address - Fax:
Practice Address - Street 1:609 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:OH
Practice Address - Zip Code:45619-1038
Practice Address - Country:US
Practice Address - Phone:740-451-0680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH187504101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)