Provider Demographics
NPI:1699914275
Name:BOOTH, RENEE DARLENE
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:DARLENE
Last Name:BOOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:RENEE
Other - Middle Name:DARLENE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:125 DONS WAY
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6478
Mailing Address - Country:US
Mailing Address - Phone:501-624-7111
Mailing Address - Fax:501-620-5109
Practice Address - Street 1:1615 MLK BLVD
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-2233
Practice Address - Country:US
Practice Address - Phone:501-332-5236
Practice Address - Fax:501-620-5109
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0907062101Y00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116399726Medicaid