Provider Demographics
NPI:1629794847
Name:BOOTH, KATHLEEN GRACE
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GRACE
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 1:2555 N CLARK ST APT 1903
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1758
Mailing Address - Country:US
Mailing Address - Phone:414-801-6267
Mailing Address - Fax:
Practice Address - Street 1:2755 N PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-6109
Practice Address - Country:US
Practice Address - Phone:312-259-2665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health