Provider Demographics
NPI:1982145058
Name:BOOTH, MALGORZATA (LAC)
Entity type:Individual
Prefix:
First Name:MALGORZATA
Middle Name:
Last Name:BOOTH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18841 ACCOKEEK TER
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-8453
Mailing Address - Country:US
Mailing Address - Phone:703-300-0797
Mailing Address - Fax:
Practice Address - Street 1:520 N WASHINGTON ST STE 100
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3538
Practice Address - Country:US
Practice Address - Phone:703-300-0797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000836171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist