Healthcare Provider Details

I. General information

NPI: 1174193635
Provider Name (Legal Business Name): KAYLA BOOTH LCAS-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4009 BARRETT DR STE 100
RALEIGH NC
27609-6616
US

IV. Provider business mailing address

4009 BARRETT DR STE 100
RALEIGH NC
27609-6616
US

V. Phone/Fax

Practice location:
  • Phone: 919-848-0132
  • Fax:
Mailing address:
  • Phone: 919-848-0132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number26968
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: