1043242852 NPI number — DR. BRIDGET KATHLEEN BOOTH PHD PMHCNS-BC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043242852 NPI number — DR. BRIDGET KATHLEEN BOOTH PHD PMHCNS-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOOTH
Provider First Name:
BRIDGET
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD PMHCNS-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOOTH
Provider Other First Name:
BRIDGET
Provider Other Middle Name:
KATHLEEN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD LCSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1043242852
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
96 ROGERS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LILLINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27546-7305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-580-4856
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 RAMSEY ST
Provider Second Line Business Practice Location Address:
VA MEDICAL CENTER
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-488-2120
Provider Business Practice Location Address Fax Number:
910-822-7017
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C004317 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0809X , with the licence number: 193660 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: BO261381 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: IP156708 . This is a "MAGELLAN BEHAVIORAL HEALT" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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