Provider Demographics
NPI:1750113791
Name:BOOTHE, ALI SELASSIE SR
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:SELASSIE
Last Name:BOOTHE
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MAY ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-1422
Mailing Address - Country:US
Mailing Address - Phone:774-530-6363
Mailing Address - Fax:
Practice Address - Street 1:90 MADISON ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-2058
Practice Address - Country:US
Practice Address - Phone:774-530-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator