Healthcare Provider Details

I. General information

NPI: 1932200805
Provider Name (Legal Business Name): KIMBERLY KATHLENE BOOTH M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 09/03/2022
Certification Date: 09/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16102 N FLORIDA AVE
LUTZ FL
33549-6129
US

IV. Provider business mailing address

16102 N FLORIDA AVE
LUTZ FL
33549-6129
US

V. Phone/Fax

Practice location:
  • Phone: 813-873-1936
  • Fax: 813-873-8837
Mailing address:
  • Phone: 813-873-1936
  • Fax: 813-873-8837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA3850
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: