Healthcare Provider Details

I. General information

NPI: 1063685907
Provider Name (Legal Business Name): MEGAN SUZANNE BOOTH LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S MONROE ST
MONROE MI
48161-1440
US

IV. Provider business mailing address

14930 LAPLAISANCE RD
MONROE MI
48161-3880
US

V. Phone/Fax

Practice location:
  • Phone: 734-457-5439
  • Fax:
Mailing address:
  • Phone: 734-241-0180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL1210231
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: