Provider Demographics
NPI:1972778793
Name:BOOTH, MARY VICTORIA (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:VICTORIA
Last Name:BOOTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 21ST ST
Mailing Address - Street 2:104
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-1752
Mailing Address - Country:US
Mailing Address - Phone:916-451-0310
Mailing Address - Fax:
Practice Address - Street 1:2015 21ST ST
Practice Address - Street 2:104
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-1752
Practice Address - Country:US
Practice Address - Phone:916-451-0310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS63131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical