Basic Information
| Provider Information | |||||||||
| NPI: | 1629052659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOOTH | ||||||||
| FirstName: | KRISTI | ||||||||
| MiddleName: | LYN | ||||||||
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| Credential: | OT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SAUSE | ||||||||
| OtherFirstName: | KRISTI | ||||||||
| OtherMiddleName: | LYN | ||||||||
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| OtherCredential: | OT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11481 SW HALL BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5034431402 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 E PARKCENTER BLVD | ||||||||
| Address2: | SUITE 114 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837066504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084339211 | ||||||||
| FaxNumber: | 2084339241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | OT495 | ID | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | OT00002780 | WA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 1013068 | OR | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.