Provider Demographics
NPI:1295006872
Name:BOOTH, LISA MICHELLE
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MICHELLE
Last Name:BOOTH
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 1:9409 E 65TH ST
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-4920
Mailing Address - Country:US
Mailing Address - Phone:816-812-4898
Mailing Address - Fax:
Practice Address - Street 1:9409 E 65TH ST
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-4920
Practice Address - Country:US
Practice Address - Phone:816-812-4898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist