Provider Demographics
NPI:1700647658
Name:BOOTHE, AMANDA JANE (MSW, LGSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JANE
Last Name:BOOTHE
Suffix:
Gender:F
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JANE
Other - Last Name:LILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:108 MCCLURE ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-6040
Mailing Address - Country:US
Mailing Address - Phone:681-422-9682
Mailing Address - Fax:
Practice Address - Street 1:310 GEORGE ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2653
Practice Address - Country:US
Practice Address - Phone:681-238-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00946732104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker