Basic Information
| Provider Information | |||||||||
| NPI: | 1043488414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOOTHE | ||||||||
| FirstName: | KRYSTAL | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 418 N DALTON AVE | ||||||||
| Address2: | |||||||||
| City: | AZUSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917023634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106210150 | ||||||||
| FaxNumber: | 6617270006 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 LAKES DR | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917902924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106210150 | ||||||||
| FaxNumber: | 6617270006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2008 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW71811 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 99999999999999 | 05 | CA | MEDICAID | 9999999999 | 01 | CA | BLUE CROSS | OTHER |