MEDICARE: MRS. SARA M BOOTH LISW-S

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	104100000X	Social Worker	I.0700284-SUPV	OH

General Provider Information

NPI Number	:	1851553069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SARA M BOOTH LISW-S

Provider Business Mailing Address
First Line	:	7225 E FIRELANDS DR
Second Line	:
City	:	HUDSON
State	:	OH
Zip	:	44236-2450
Country	:	US
Telephone Number	:	216-269-2978
Fax Number	:

Provider Business Practice Location Address
First Line	:	4979 MAYFIELD RD
Second Line	:
City	:	LYNDHURST
State	:	OH
Zip	:	44124-2601
Country	:	US
Telephone Number	:	216-839-2273
Fax Number	:

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

Provider Enumeration Date	:	06/28/2008
Last Update Date	:	06/28/2008

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