Healthcare Provider Details

I. General information

NPI: 1326320391
Provider Name (Legal Business Name): HEATHER RENEE BOOTH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 MALLARD CT
BECKLEY WV
25801-3664
US

IV. Provider business mailing address

28 MALLARD CT
BECKLEY WV
25801-3664
US

V. Phone/Fax

Practice location:
  • Phone: 304-252-8409
  • Fax: 304-252-0022
Mailing address:
  • Phone: 304-252-8409
  • Fax: 304-252-0022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberAP02943057
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: