Provider Demographics
NPI:1851799324
Name:MICHELLE BOOTH, LCSW
Entity Type:Organization
Organization Name:MICHELLE BOOTH, LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:571-477-0096
Mailing Address - Street 1:7514 POLLEN ST
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1639
Mailing Address - Country:US
Mailing Address - Phone:703-339-8845
Mailing Address - Fax:
Practice Address - Street 1:10560 MAIN ST
Practice Address - Street 2:SUITE 405
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7182
Practice Address - Country:US
Practice Address - Phone:571-477-0096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040069471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty