Provider Demographics
NPI:1699840165
Name:BOOTH, ASHLEY LANNEN (HSP-PA)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LANNEN
Last Name:BOOTH
Suffix:
Gender:M
Credentials:HSP-PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28340-0369
Mailing Address - Country:US
Mailing Address - Phone:910-628-6718
Mailing Address - Fax:910-628-6719
Practice Address - Street 1:302 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340-1730
Practice Address - Country:US
Practice Address - Phone:910-628-6718
Practice Address - Fax:910-628-6719
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0803103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107276Medicaid