Provider Demographics
NPI:1043242852
Name:BOOTH, BRIDGET KATHLEEN (PHD PMHCNS-BC)
Entity type:Individual
Prefix:DR
First Name:BRIDGET
Middle Name:KATHLEEN
Last Name:BOOTH
Suffix:
Gender:F
Credentials:PHD PMHCNS-BC
Other - Prefix:DR
Other - First Name:BRIDGET
Other - Middle Name:KATHLEEN
Other - Last Name:BOOTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD LCSW
Mailing Address - Street 1:96 ROGERS RD
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-7305
Mailing Address - Country:US
Mailing Address - Phone:910-580-4856
Mailing Address - Fax:
Practice Address - Street 1:2300 RAMSEY ST
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301
Practice Address - Country:US
Practice Address - Phone:910-488-2120
Practice Address - Fax:910-822-7017
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0043171041C0700X
NC193660364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABO261381OtherBLUE CROSS BLUE SHIELD
PAIP156708OtherMAGELLAN BEHAVIORAL HEALT
BO959050Medicare PIN
PAS42354Medicare UPIN
BO959050Medicare ID - Type Unspecified