Provider Demographics
NPI:1801193834
Name:BOOKER, EDNA FAYE (LPC, LAC, LISAC)
Entity Type:Individual
Prefix:MRS
First Name:EDNA
Middle Name:FAYE
Last Name:BOOKER
Suffix:
Gender:F
Credentials:LPC, LAC, LISAC
Other - Prefix:MS
Other - First Name:EDNA
Other - Middle Name:FAYE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:4885 BUCK SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-8139
Mailing Address - Country:US
Mailing Address - Phone:928-266-8600
Mailing Address - Fax:760-314-7442
Practice Address - Street 1:222 E MAIN ST STE 117
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2361
Practice Address - Country:US
Practice Address - Phone:760-255-1497
Practice Address - Fax:760-256-2920
Is Sole Proprietor?:No
Enumeration Date:2011-02-28
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5034101YA0400X
AZ15179101YA0400X
AZ17302101YP2500X
LA4179101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1801193834Medicaid