Healthcare Provider Details

I. General information

NPI: 1346221876
Provider Name (Legal Business Name): STEPHEN R BOOTH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 W BARNEY ST
GOUVERNEUR NY
13642-1040
US

IV. Provider business mailing address

77 W BARNEY ST
GOUVERNEUR NY
13642-1040
US

V. Phone/Fax

Practice location:
  • Phone: 315-535-9202
  • Fax: 315-535-9207
Mailing address:
  • Phone: 315-535-9202
  • Fax: 315-535-9207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number004584
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: