Provider Demographics
NPI:1801255419
Name:BOOTH, DEANA (LPTA)
Entity type:Individual
Prefix:
First Name:DEANA
Middle Name:
Last Name:BOOTH
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3160 N BELSAY RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48506-2276
Mailing Address - Country:US
Mailing Address - Phone:810-241-2412
Mailing Address - Fax:
Practice Address - Street 1:G1071 N BALLENGER HWY
Practice Address - Street 2:STE 105
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-4453
Practice Address - Country:US
Practice Address - Phone:810-262-7899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001929225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant