Provider Demographics
NPI:1366831588
Name:BOOTH, PHYLLIS BARNES (MA, LMFT, LCPC)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:BARNES
Last Name:BOOTH
Suffix:
Gender:F
Credentials:MA, LMFT, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5550 SOUTH SOUTH SHORE DRIVE
Mailing Address - Street 2:#1415
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637
Mailing Address - Country:US
Mailing Address - Phone:773-753-4674
Mailing Address - Fax:
Practice Address - Street 1:5550 SO. SOUTH SHORE DRIVE
Practice Address - Street 2:#1415
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:773-753-4674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-000-574101YP2500X
IL166-000-152106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional