Healthcare Provider Details

I. General information

NPI: 1033611637
Provider Name (Legal Business Name): KIMBERLY BOOTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 FULTON AVE STE 235
SACRAMENTO CA
95825
US

IV. Provider business mailing address

8625 ASHBURY CT
ROSEVILLE CA
95747-6350
US

V. Phone/Fax

Practice location:
  • Phone: 916-974-2599
  • Fax:
Mailing address:
  • Phone: 916-216-2826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: