1124342167 NPI number — KRISTEN M. BOOTHE A MARRIAGE AND FAMILY COUNSELING CORPORATION

Table of content: (NPI 1124342167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124342167 NPI number — KRISTEN M. BOOTHE A MARRIAGE AND FAMILY COUNSELING CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KRISTEN M. BOOTHE A MARRIAGE AND FAMILY COUNSELING CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124342167
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 JEFFERSON ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
FAIRFIELD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94533-5511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-631-9906
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 JEFFERSON ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FAIRFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94533-5511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-631-9906
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BOOTHE
Authorized Official First Name:
KRISTEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT- LICENSED MFT
Authorized Official Telephone Number:
707-631-9906

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MFC42128 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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