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NPI Code Detail

MEDICARE: MARLENE ANGELA BOOTHE

MEDICARE: MARLENE ANGELA BOOTHE
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
1106S00000XBehavior Technician
2390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1700337839
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARLENE ANGELA BOOTHE
Provider Business Mailing Address
First Line : PO BOX 33568
Second Line :
City : SAN DIEGO
State : CA
Zip : 92163-3568
Country : US
Telephone Number : 855-223-7123
Fax Number : 619-374-7134
Provider Business Practice Location Address
First Line : 2453 GRAND CANAL BLVD STE A
Second Line :
City : STOCKTON
State : CA
Zip : 95207-8138
Country : US
Telephone Number : 855-223-7123
Fax Number : 619-374-7134
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/24/2016
Last Update Date : 08/18/2023

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Directions to “ MARLENE ANGELA BOOTHE ” Practice Location

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