Provider Demographics
NPI:1083802094
Name:BOOTH, CHAD A (LSW)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:A
Last Name:BOOTH
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1072 JESSE BARTLETT CT
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7515
Mailing Address - Country:US
Mailing Address - Phone:219-872-8666
Mailing Address - Fax:
Practice Address - Street 1:450 SAINT JOHN RD
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7354
Practice Address - Country:US
Practice Address - Phone:219-872-8666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33005318A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical