Provider Demographics
NPI:1992393318
Name:BOOSE, ISSAC LUTHER JR (LPC, LMFT)
Entity Type:Individual
Prefix:
First Name:ISSAC
Middle Name:LUTHER
Last Name:BOOSE
Suffix:JR
Gender:M
Credentials:LPC, LMFT
Other - Prefix:MR
Other - First Name:ISSAC
Other - Middle Name:LUTHER
Other - Last Name:BOOSE
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:ISSAC L BOOSE
Mailing Address - Street 1:57 GRIFFIN RD
Mailing Address - Street 2:
Mailing Address - City:RICHTON
Mailing Address - State:MS
Mailing Address - Zip Code:39476-9224
Mailing Address - Country:US
Mailing Address - Phone:601-408-8828
Mailing Address - Fax:
Practice Address - Street 1:57 GRIFFIN RD
Practice Address - Street 2:
Practice Address - City:RICHTON
Practice Address - State:MS
Practice Address - Zip Code:39476-9224
Practice Address - Country:US
Practice Address - Phone:601-408-8828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-03
Last Update Date:2021-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS883101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor