Provider Demographics
NPI:1578714846
Name:BOOTH, BRET A
Entity Type:Individual
Prefix:DR
First Name:BRET
Middle Name:A
Last Name:BOOTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 W NC HIGHWAY 54
Mailing Address - Street 2:STE 103
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5572
Mailing Address - Country:US
Mailing Address - Phone:919-859-9040
Mailing Address - Fax:919-859-9030
Practice Address - Street 1:1540 SUNDAY DR
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6000
Practice Address - Country:US
Practice Address - Phone:919-859-9040
Practice Address - Fax:919-859-9030
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3637103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical