Provider Demographics
NPI:1245600840
Name:BOOTH, JOHN (MFT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BOOTH
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:LJ
Other - Middle Name:
Other - Last Name:BOOTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:E1494 COUNTY ROAD Q
Mailing Address - Street 2:
Mailing Address - City:SCANDINAVIA
Mailing Address - State:WI
Mailing Address - Zip Code:54977-9727
Mailing Address - Country:US
Mailing Address - Phone:715-467-2442
Mailing Address - Fax:
Practice Address - Street 1:520 N 28TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4101
Practice Address - Country:US
Practice Address - Phone:715-845-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI479-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist