Provider Demographics
NPI:1043488414
Name:BOOTHE, KRYSTAL MARIE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:MARIE
Last Name:BOOTHE
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 ISLAND VISTA DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76005-1375
Mailing Address - Country:US
Mailing Address - Phone:310-621-0150
Mailing Address - Fax:661-727-0006
Practice Address - Street 1:117 E COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-1938
Practice Address - Country:US
Practice Address - Phone:661-402-1545
Practice Address - Fax:661-727-0006
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW718111041C0700X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9999999999OtherBLUE CROSS
CA99999999999999Medicaid