Provider Demographics
NPI:1285050195
Name:BOOTH, BRENDA WILKINSON
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:WILKINSON
Last Name:BOOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 BENMAR DR
Mailing Address - Street 2:SUITE 2295
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-3165
Mailing Address - Country:US
Mailing Address - Phone:281-201-5124
Mailing Address - Fax:
Practice Address - Street 1:440 BENMAR DR
Practice Address - Street 2:SUITE 2295
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-3165
Practice Address - Country:US
Practice Address - Phone:281-201-5124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-16
Last Update Date:2014-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66118101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170014444763Medicaid