Provider Demographics
NPI:1750469722
Name:BOOTH, MITZI DAVIS (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MITZI
Middle Name:DAVIS
Last Name:BOOTH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15845 E 77TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-7092
Mailing Address - Country:US
Mailing Address - Phone:918-272-5209
Mailing Address - Fax:
Practice Address - Street 1:2208 W DETROIT ST STE 202
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-3642
Practice Address - Country:US
Practice Address - Phone:918-806-0106
Practice Address - Fax:918-806-0113
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3142235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKY200061310AMedicaid