Provider Demographics
NPI:1366033193
Name:BOOTH, TONYA DANIELLE
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:DANIELLE
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 1:752 RICHMOND RD N
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-1059
Mailing Address - Country:US
Mailing Address - Phone:859-979-6999
Mailing Address - Fax:
Practice Address - Street 1:625 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1550
Practice Address - Country:US
Practice Address - Phone:859-582-0159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY267547225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
267547OtherOT LICENSE