Provider Demographics
NPI:1780964494
Name:BOOTH, LERA BETHANY (RD LD)
Entity type:Individual
Prefix:MRS
First Name:LERA
Middle Name:BETHANY
Last Name:BOOTH
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 W GIBSON ST
Mailing Address - Street 2:
Mailing Address - City:HARTWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30643-1847
Mailing Address - Country:US
Mailing Address - Phone:706-856-6245
Mailing Address - Fax:
Practice Address - Street 1:138 W GIBSON ST
Practice Address - Street 2:
Practice Address - City:HARTWELL
Practice Address - State:GA
Practice Address - Zip Code:30643-1847
Practice Address - Country:US
Practice Address - Phone:706-856-6245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002511133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered