Provider Demographics
NPI:1780290486
Name:BOOTHE, MACKENZIE C (DPT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:C
Last Name:BOOTHE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:MACK
Other - Middle Name:C
Other - Last Name:BOOTHE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:5045 BENTLEY DR STE 190
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-7010
Practice Address - Country:US
Practice Address - Phone:515-226-1616
Practice Address - Fax:515-226-1620
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101593225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist