Healthcare Provider Details

I. General information

NPI: 1851618615
Provider Name (Legal Business Name): GAYLE O BOOTH MS RD LDN CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GAYLE ANN OVERMYER

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N NORTH CT SUITE 270
PALATINE IL
60067-8157
US

IV. Provider business mailing address

415 MACHELLE DR
CARY IL
60013-2399
US

V. Phone/Fax

Practice location:
  • Phone: 847-701-8345
  • Fax: 888-788-2497
Mailing address:
  • Phone: 847-701-8345
  • Fax: 888-788-2497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.001309
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number164.001309
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number164.001309
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: