Provider Demographics
NPI:1962607879
Name:BOOTH, URSULA YVONNE (PT)
Entity type:Individual
Prefix:MS
First Name:URSULA
Middle Name:YVONNE
Last Name:BOOTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-416-9100
Mailing Address - Fax:586-416-9103
Practice Address - Street 1:8628 PURDUE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1114
Practice Address - Country:US
Practice Address - Phone:317-677-0660
Practice Address - Fax:317-677-0640
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004557A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000525491OtherANTHEM/BCBS PIN
IN200862840Medicaid
IN1235335985OtherGROUP NPI
IN200848350BMedicaid
IN11758517OtherCAQH
IN1235335985OtherGROUP NPI
IN243320DMedicare PIN