Provider Demographics
NPI:1316050370
Name:BOOTH PSYCHOLOGICAL AND EDUCATIONAL SERVICES, INC
Entity type:Organization
Organization Name:BOOTH PSYCHOLOGICAL AND EDUCATIONAL SERVICES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:918-749-9357
Mailing Address - Street 1:6140 S FLORENCE PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-1201
Mailing Address - Country:US
Mailing Address - Phone:918-749-9357
Mailing Address - Fax:
Practice Address - Street 1:6140 S FLORENCE PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1201
Practice Address - Country:US
Practice Address - Phone:918-749-9357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK121103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========-001OtherBLUE CROSS BLUE SHIELD
OK443363932Medicare PIN