Provider Demographics
NPI:1326663238
Name:BOOTH, SHELBY (MA)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:BOOTH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 558
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-0558
Mailing Address - Country:US
Mailing Address - Phone:517-333-8550
Mailing Address - Fax:
Practice Address - Street 1:830 W LAKE LANSING RD STE 190
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6371
Practice Address - Country:US
Practice Address - Phone:517-333-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7151001729235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist