MEDICARE: GRANT BOOTH PA DBA BOOTH THERAPY

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1861915001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANT BOOTH PA DBA BOOTH THERAPY

Provider Business Mailing Address
First Line	:	1499 LINCOLN AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2236
Country	:	US
Telephone Number	:	651-690-1542
Fax Number	:

Provider Business Practice Location Address
First Line	:	1499 LINCOLN AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2236
Country	:	US
Telephone Number	:	651-690-1542
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST/CLINICAL SOCIAL WORKER
Name	:	GRANT EDWARD BOOTH
Credential	:	MSW, LICSW, ACSW
Telephone Number	:	651-690-1542

Provider Enumeration Date	:	07/19/2017
Last Update Date	:	07/21/2022

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