Healthcare Provider Details

I. General information

NPI: 1578714846
Provider Name (Legal Business Name): DR. BRET A BOOTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 SUNDAY DR SUITE 200
RALEIGH NC
27607-6000
US

IV. Provider business mailing address

1502 W NC HIGHWAY 54 STE 103
DURHAM NC
27707-5572
US

V. Phone/Fax

Practice location:
  • Phone: 919-859-9040
  • Fax: 919-859-9030
Mailing address:
  • Phone: 919-859-9040
  • Fax: 919-859-9030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3637
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3637
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: