Provider Demographics
NPI:1801937826
Name:BOOTH, MARY KAY (BA, CASAC, LMHC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KAY
Last Name:BOOTH
Suffix:
Gender:F
Credentials:BA, CASAC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 BROOKVIEW AVENUE
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760
Mailing Address - Country:US
Mailing Address - Phone:585-375-1398
Mailing Address - Fax:
Practice Address - Street 1:118 BROOKVIEW AVENUE
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760
Practice Address - Country:US
Practice Address - Phone:585-375-1398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001771101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00635070Medicaid
NY20-8258921OtherEMPLOYER IDENTIFICATION #