Provider Demographics
NPI:1366034001
Name:BOOTH, MARIAH
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:
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:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:POCA
Mailing Address - State:WV
Mailing Address - Zip Code:25159-0128
Mailing Address - Country:US
Mailing Address - Phone:304-769-8077
Mailing Address - Fax:
Practice Address - Street 1:1611 CHARLESTON RD
Practice Address - Street 2:
Practice Address - City:POCA
Practice Address - State:WV
Practice Address - Zip Code:25159-2515
Practice Address - Country:US
Practice Address - Phone:304-769-8077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care