Healthcare Provider Details

I. General information

NPI: 1003627290
Provider Name (Legal Business Name): AVERIE JACQUELINE BOOTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 AYERS CIR
SUMMERVILLE SC
29485-3303
US

IV. Provider business mailing address

4275 OHEAR AVE
NORTH CHARLESTON SC
29405-5099
US

V. Phone/Fax

Practice location:
  • Phone: 843-460-2605
  • Fax:
Mailing address:
  • Phone:
  • Fax: 888-298-0519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number1543540
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPC009921
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: