Provider Demographics
NPI:1831128339
Name:BOOTH, CASSIANNE SUMMERLIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:CASSIANNE
Middle Name:SUMMERLIN
Last Name:BOOTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:CASSIANNE
Other - Middle Name:
Other - Last Name:SUMMERLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:708 MOBJACK PL
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1957
Mailing Address - Country:US
Mailing Address - Phone:757-873-1958
Mailing Address - Fax:757-873-2143
Practice Address - Street 1:708 MOBJACK PL
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-1957
Practice Address - Country:US
Practice Address - Phone:757-873-1958
Practice Address - Fax:757-873-2143
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001464103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA056563OtherANTHEM BC/BS
VA080925OtherSENTARA
VA219661OtherMAMSI