Basic Information
| Provider Information | |||||||||
| NPI: | 1043242852 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOOTH | ||||||||
| FirstName: | BRIDGET | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD PMHCNS-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOOTH | ||||||||
| OtherFirstName: | BRIDGET | ||||||||
| OtherMiddleName: | KATHLEEN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD LCSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 96 ROGERS RD | ||||||||
| Address2: | |||||||||
| City: | LILLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275467305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105804856 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2300 RAMSEY ST | ||||||||
| Address2: | VA MEDICAL CENTER | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104882120 | ||||||||
| FaxNumber: | 9108227017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C004317 | NC | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 364SP0809X | 193660 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | BO261381 | 01 | PA | BLUE CROSS BLUE SHIELD | OTHER | IP156708 | 01 | PA | MAGELLAN BEHAVIORAL HEALT | OTHER |