Provider Demographics
NPI:1063380475
Name:BOOTH, SAM (MA)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:BOOTH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9329 ILLINOIS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5796
Mailing Address - Country:US
Mailing Address - Phone:260-444-6045
Mailing Address - Fax:
Practice Address - Street 1:9329 ILLINOIS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-5796
Practice Address - Country:US
Practice Address - Phone:260-444-6045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-27
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty