Provider Demographics
NPI:1063434892
Name:BOOTH, SUSAN L
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:BOOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505
Mailing Address - Country:US
Mailing Address - Phone:330-759-2603
Mailing Address - Fax:330-759-2569
Practice Address - Street 1:4451A MAHONING AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483
Practice Address - Country:US
Practice Address - Phone:330-847-0919
Practice Address - Fax:330-847-0728
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3399225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000168546OtherANTHEM GROUP
OH2083169Medicaid
OH2083169Medicaid