Provider Demographics
NPI:1386133205
Name:BOOTH, KRISTIN NICOLE (COTA/L)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NICOLE
Last Name:BOOTH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 FAULKLAND RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-2504
Mailing Address - Country:US
Mailing Address - Phone:302-824-2002
Mailing Address - Fax:
Practice Address - Street 1:549 BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-1020
Practice Address - Country:US
Practice Address - Phone:610-558-7417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP008883224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant