Healthcare Provider Details

I. General information

NPI: 1669217097
Provider Name (Legal Business Name): SONDRA MARIE BOOTH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 9TH AVE S UNIT 20
NORTH MYRTLE BEACH SC
29582-3488
US

IV. Provider business mailing address

829 9TH AVE S UNIT 20
NORTH MYRTLE BEACH SC
29582-3488
US

V. Phone/Fax

Practice location:
  • Phone: 843-997-2443
  • Fax:
Mailing address:
  • Phone: 843-997-2443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12254
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: