MEDICARE: KRISTEN BOOTHE MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC42128	CA

General Provider Information

NPI Number	:	1366644262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN BOOTHE MFT

Provider Business Mailing Address
First Line	:	1652 TEXAS ST
Second Line	:	SUITE 129
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-5952
Country	:	US
Telephone Number	:	707-631-9906
Fax Number	:

Provider Business Practice Location Address
First Line	:	1652 TEXAS ST
Second Line	:	SUITE 129
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-5952
Country	:	US
Telephone Number	:	707-631-9906
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2007
Last Update Date	:	07/08/2007

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Directions to “ KRISTEN BOOTHE MFT” Practice Location

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