Provider Demographics
NPI:1093480949
Name:BOOTH, LOLA MARIE (LADC)
Entity Type:Individual
Prefix:
First Name:LOLA
Middle Name:MARIE
Last Name:BOOTH
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 8TH STREET SOUTHEAST
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-4219
Mailing Address - Country:US
Mailing Address - Phone:218-844-9730
Mailing Address - Fax:218-844-7754
Practice Address - Street 1:921 8TH ST SE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-2840
Practice Address - Country:US
Practice Address - Phone:218-844-9730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2021-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305800101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty