Provider Demographics
NPI:1497395693
Name:BOOTH, TIARA (SLP)
Entity Type:Individual
Prefix:
First Name:TIARA
Middle Name:
Last Name:BOOTH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CAMPUS WAY N
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2892
Mailing Address - Country:US
Mailing Address - Phone:301-276-9153
Mailing Address - Fax:
Practice Address - Street 1:2900 CAMPUS WAY N
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-2892
Practice Address - Country:US
Practice Address - Phone:301-276-9153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01818L235Z00000X
VA2202010198235Z00000X
MD09346235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2202010198OtherSTATE DEPARTMENT OF HEALTH
MD01818LOtherSTATE DEPARTMENT OF HEALTH
MD09346OtherSTATE DEPARTMENT OF HEALTH