Healthcare Provider Details

I. General information

NPI: 1043242852
Provider Name (Legal Business Name): BRIDGET KATHLEEN BOOTH PHD PMHCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRIDGET KATHLEEN BOOTH PHD LCSW

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 RAMSEY ST VA MEDICAL CENTER
FAYETTEVILLE NC
28301
US

IV. Provider business mailing address

96 ROGERS RD
LILLINGTON NC
27546-7305
US

V. Phone/Fax

Practice location:
  • Phone: 910-488-2120
  • Fax: 910-822-7017
Mailing address:
  • Phone: 910-580-4856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC004317
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number193660
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: