Provider Demographics
NPI:1427886951
Name:BOOTHBY, RICHARD JR (MS, TLMHC)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BOOTHBY
Suffix:JR
Gender:M
Credentials:MS, TLMHC
Other - Prefix:
Other - First Name:PETE
Other - Middle Name:
Other - Last Name:BOOTHBY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, TLMHC
Mailing Address - Street 1:427 E KANESVILLE BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-4403
Mailing Address - Country:US
Mailing Address - Phone:712-254-9018
Mailing Address - Fax:
Practice Address - Street 1:427 E KANESVILLE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4403
Practice Address - Country:US
Practice Address - Phone:712-254-9018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA126958101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health