Provider Demographics
NPI:1215160403
Name:BOOTH, TEDDY WAYNE II (LCSW)
Entity type:Individual
Prefix:
First Name:TEDDY
Middle Name:WAYNE
Last Name:BOOTH
Suffix:II
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1167 SPRATLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-6205
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:109 W WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5621
Practice Address - Country:US
Practice Address - Phone:423-232-2600
Practice Address - Fax:423-467-3644
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-03
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10861041C0700X
TN33671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1515202Medicaid
VA1215160403 WATAUGAMedicaid
TN1515202Medicaid
VA1215160403 WATAUGAMedicaid