Provider Demographics
NPI:1629052659
Name:BOOTH, KRISTI LYN (OT)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:LYN
Last Name:BOOTH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:KRISTI
Other - Middle Name:LYN
Other - Last Name:SAUSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OT
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:415 E PARKCENTER BLVD
Practice Address - Street 2:SUITE 114
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6504
Practice Address - Country:US
Practice Address - Phone:208-433-9211
Practice Address - Fax:208-433-9241
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT495235Z00000X
WAOT00002780235Z00000X
OR1013068235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist