Provider Demographics
NPI:1447755194
Name:BOOTH, LISA ELISOFON
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ELISOFON
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 1:6026 RIVER BIRCH CT
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-1058
Mailing Address - Country:US
Mailing Address - Phone:443-956-0196
Mailing Address - Fax:
Practice Address - Street 1:8815 COLUMBIA 100 PKWY STE 4
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2361
Practice Address - Country:US
Practice Address - Phone:877-776-8502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
164-961-7952OtherCHILDREN'S SPOT