Provider Demographics
NPI:1477725943
Name:BOOTY, MARJORIE LETARDE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:LETARDE
Last Name:BOOTY
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 ONEONTA ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-1130
Mailing Address - Country:US
Mailing Address - Phone:318-550-7164
Mailing Address - Fax:
Practice Address - Street 1:816 ONEONTA ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-1130
Practice Address - Country:US
Practice Address - Phone:318-550-7164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6479101YM0800X
SC93011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health