Provider Demographics
NPI:1336377902
Name:BOOTH, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BOOTH
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 1:108 SNYDER LN
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-7521
Mailing Address - Country:US
Mailing Address - Phone:570-523-8049
Mailing Address - Fax:
Practice Address - Street 1:245 E 8TH ST
Practice Address - Street 2:
Practice Address - City:WATSONTOWN
Practice Address - State:PA
Practice Address - Zip Code:17777-1033
Practice Address - Country:US
Practice Address - Phone:570-538-2561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program