Provider Demographics
NPI:1588987549
Name:BOOTH, MELISSA (MPT)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:BOOTH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-1440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:460 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-1440
Practice Address - Country:US
Practice Address - Phone:435-654-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5971534-2401174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist