Provider Demographics
NPI:1831768258
Name:BOOTH, ROBERT JOHN
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JOHN
Last Name:BOOTH
Suffix:
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 1:1809 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-2510
Mailing Address - Country:US
Mailing Address - Phone:877-300-9101
Mailing Address - Fax:
Practice Address - Street 1:2500 E ENTERPRISE AVE STE B
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8556
Practice Address - Country:US
Practice Address - Phone:920-416-8577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42251300Medicaid