Provider Demographics
NPI:1003627290
Name:BOOTH, AVERIE JACQUELINE
Entity type:Individual
Prefix:
First Name:AVERIE
Middle Name:JACQUELINE
Last Name:BOOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 MALL BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-4864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 MALL BULV
Practice Address - Street 2:SUITE E
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406
Practice Address - Country:US
Practice Address - Phone:912-349-4955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC009921101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health