Provider Demographics
NPI:1740602770
Name:BOOTS, MARY (IADC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BOOTS
Suffix:
Gender:F
Credentials:IADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4403 1ST AVE SE STE 307
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-3221
Mailing Address - Country:US
Mailing Address - Phone:319-294-1599
Mailing Address - Fax:
Practice Address - Street 1:4403 1ST AVE SE STE 307
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-3221
Practice Address - Country:US
Practice Address - Phone:319-294-1599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA11063101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)