Healthcare Provider Details

I. General information

NPI: 1639434582
Provider Name (Legal Business Name): PATRICK ROBERT BOOTH M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 SPENCER ST STE 118
LAS VEGAS NV
89119-5250
US

IV. Provider business mailing address

7261 W CHARLESTON BLVD SUITE 101
LAS VEGAS NV
89117-1636
US

V. Phone/Fax

Practice location:
  • Phone: 702-799-9710
  • Fax:
Mailing address:
  • Phone: 702-396-0101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-16-16491
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNV
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-35356
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: