Provider Demographics
NPI:1902219819
Name:BOOTHE, MARK
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:BOOTHE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:ANTHONY
Other - Last Name:BOOTHE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:7230 HERITAGE VILLAGE PLAZA SUITE 202
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155
Mailing Address - Country:US
Mailing Address - Phone:703-754-0636
Mailing Address - Fax:703-754-0646
Practice Address - Street 1:1629 K ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-1602
Practice Address - Country:US
Practice Address - Phone:703-754-0636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC3035561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical