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General NPI Number Information
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NPI Number | 1679694327
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Entity Type | Organization
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Legal Business Name | BOOTH & COMPANY, INC.
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Dates
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Enumeration Date | 04/02/2007
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Last Update Date | 10/01/2024
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Provider Practice Location Address
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Address Line | 9329 ILLINOIS RD
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City | FORT WAYNE
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State | IN
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Zip | 46804-5796
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Country | US
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Telephone | 260-755-5896
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Fax | 260-755-5927
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Provider Business Mailing Address
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Address Line | 9329 ILLINOIS RD
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City | FORT WAYNE
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State | IN
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Zip | 46804-5796
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Country | US
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Telephone | 260-755-5896
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Fax | 260-755-5927
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SPENCER JENKINS BOOTH
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Credential | PSY.D., HSPP
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Telephone | 260-417-4885
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 20041340A
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License Number State | IN
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