Provider Demographics
NPI:1871600478
Name:BOOTH, VICKI M (MA CTRS)
Entity type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:M
Last Name:BOOTH
Suffix:
Gender:F
Credentials:MA CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 VETERANS DR
Mailing Address - Street 2:A-116-DOM
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98493
Mailing Address - Country:US
Mailing Address - Phone:253-582-8440
Mailing Address - Fax:
Practice Address - Street 1:9900 VETERANS DR
Practice Address - Street 2:A-116-DOM
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98493
Practice Address - Country:US
Practice Address - Phone:253-582-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARE00000165225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist