Provider Demographics
NPI:1851618615
Name:BOOTH, GAYLE O (MS RD LDN CDE)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:O
Last Name:BOOTH
Suffix:
Gender:F
Credentials:MS RD LDN CDE
Other - Prefix:
Other - First Name:GAYLE
Other - Middle Name:ANN
Other - Last Name:OVERMYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 MACHELLE DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-2399
Mailing Address - Country:US
Mailing Address - Phone:847-701-8345
Mailing Address - Fax:888-788-2497
Practice Address - Street 1:675 N NORTH CT
Practice Address - Street 2:SUITE 270
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-8157
Practice Address - Country:US
Practice Address - Phone:847-701-8345
Practice Address - Fax:888-788-2497
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-03
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.001309133V00000X, 133VN1004X, 133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1851618615Medicare PIN