Provider Demographics
NPI:1932200805
Name:BOOTH, KIMBERLY KATHLENE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:KATHLENE
Last Name:BOOTH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16102 N FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-6129
Mailing Address - Country:US
Mailing Address - Phone:813-873-1936
Mailing Address - Fax:813-873-8837
Practice Address - Street 1:16102 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-6129
Practice Address - Country:US
Practice Address - Phone:813-873-1936
Practice Address - Fax:813-873-8837
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2022-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3850235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL883512800Medicaid