Healthcare Provider Details

I. General information

NPI: 1275744351
Provider Name (Legal Business Name): CAROLE M BOOTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 S CHARLES ST FOURTH FLOOR
BALTIMORE MD
21230-3801
US

IV. Provider business mailing address

PO BOX 64277
BALTIMORE MD
21264-4277
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-2293
  • Fax: 410-328-5895
Mailing address:
  • Phone: 410-328-7037
  • Fax: 410-328-3311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberD0037653
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: