Healthcare Provider Details

I. General information

NPI: 1477264216
Provider Name (Legal Business Name): LAURA ANN BOOTH LCAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA WEST

II. Dates (important events)

Enumeration Date: 12/13/2022
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S EARL AVE STE 4A
LAFAYETTE IN
47904-3265
US

IV. Provider business mailing address

401 S EARL AVE STE 4A
LAFAYETTE IN
47904-3265
US

V. Phone/Fax

Practice location:
  • Phone: 765-297-0090
  • Fax:
Mailing address:
  • Phone: 765-297-0090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87001813A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33010727A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: