Provider Demographics
NPI:1366919615
Name:BOOTH, TARA ANGELA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:ANGELA
Last Name:BOOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:ANGELA
Other - Last Name:LADUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1032 W MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-8209
Mailing Address - Country:US
Mailing Address - Phone:518-222-7165
Mailing Address - Fax:
Practice Address - Street 1:1032 W MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-8209
Practice Address - Country:US
Practice Address - Phone:518-222-7165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health