Provider Demographics
NPI:1811460082
Name:BOOTH, MICHAEL KENT (DPT, MS, LAT, PT ATC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KENT
Last Name:BOOTH
Suffix:
Gender:M
Credentials:DPT, MS, LAT, PT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 SILVER RUN RD
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332-7313
Mailing Address - Country:US
Mailing Address - Phone:609-805-7668
Mailing Address - Fax:
Practice Address - Street 1:636 SILVER RUN RD
Practice Address - Street 2:
Practice Address - City:MILLVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08332-7313
Practice Address - Country:US
Practice Address - Phone:609-805-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT003022002255A2300X
PART0076642255A2300X
PAPT031441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer