Provider Demographics
NPI:1992174452
Name:BOOTHE, SPENCER K (PT)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:K
Last Name:BOOTHE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 ROCKBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6989
Mailing Address - Country:US
Mailing Address - Phone:601-278-3578
Mailing Address - Fax:
Practice Address - Street 1:119 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4738
Practice Address - Country:US
Practice Address - Phone:601-708-1834
Practice Address - Fax:601-708-1837
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT5603225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS200015547Medicaid