Provider Demographics
NPI:1780232728
Name:BOOTHE, MACKENZIE MAUREEN
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:MAUREEN
Last Name:BOOTHE
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 1:101 PINE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-1245
Mailing Address - Country:US
Mailing Address - Phone:360-631-4350
Mailing Address - Fax:
Practice Address - Street 1:2021 CUNNINGHAM DR STE 400
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3371
Practice Address - Country:US
Practice Address - Phone:757-838-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008602101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional