Provider Demographics
NPI:1205527819
Name:BOOTH, BRANTLEY (PMHNP)
Entity type:Individual
Prefix:
First Name:BRANTLEY
Middle Name:
Last Name:BOOTH
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 4TH AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7897
Mailing Address - Country:US
Mailing Address - Phone:337-477-7091
Mailing Address - Fax:
Practice Address - Street 1:2829 4TH AVE STE 150
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7897
Practice Address - Country:US
Practice Address - Phone:337-480-7800
Practice Address - Fax:337-474-4552
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA230060363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty