Provider Demographics
NPI:1205156171
Name:BOOTH, SUSANNE (ND, PT)
Entity type:Individual
Prefix:DR
First Name:SUSANNE
Middle Name:
Last Name:BOOTH
Suffix:
Gender:F
Credentials:ND, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 452
Mailing Address - Street 2:
Mailing Address - City:SAXTONS RIVER
Mailing Address - State:VT
Mailing Address - Zip Code:05154-0452
Mailing Address - Country:US
Mailing Address - Phone:206-919-9458
Mailing Address - Fax:802-722-4137
Practice Address - Street 1:4923 US ROUTE 5
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:VT
Practice Address - Zip Code:05158-9651
Practice Address - Country:US
Practice Address - Phone:802-722-4023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0065254225100000X
VT0990080815175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1020007Medicaid