Provider Demographics
NPI:1639419666
Name:BOOTH-SIMONSEN, MELISSA (BCBA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BOOTH-SIMONSEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:MOREHEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3241
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:CA
Mailing Address - Zip Code:95019-3241
Mailing Address - Country:US
Mailing Address - Phone:817-223-7962
Mailing Address - Fax:
Practice Address - Street 1:6 HANGAR WAY
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-2456
Practice Address - Country:US
Practice Address - Phone:831-786-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-05-2548103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst