Provider Demographics
NPI:1598276438
Name:BOOTH PSYCHOLOGICAL SOLUTIONS, PLLC
Entity Type:Organization
Organization Name:BOOTH PSYCHOLOGICAL SOLUTIONS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAYDELL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-377-1131
Mailing Address - Street 1:10 CREEKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:GARDEN VALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83622-5294
Mailing Address - Country:US
Mailing Address - Phone:208-377-1131
Mailing Address - Fax:
Practice Address - Street 1:13945 W WAINWRIGHT DR STE 106
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1925
Practice Address - Country:US
Practice Address - Phone:208-377-1131
Practice Address - Fax:208-908-7129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-211261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE