Individual
TEDDY WAYNE BOOTH II
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LCSW
Contact information
Practice address
109 W WATAUGA AVE, JOHNSON CITY, TN 37604-5621
(423) 232-2600
(423) 467-3644
Mailing address
1167 SPRATLIN PARK DR, GRAY, TN 37615-6205
(423) 467-3600
(423) 467-3644
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
1086
KY
1041C0700X
Clinical Social Worker
Primary
3367
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1215160403 WATAUGA
—
VA
05
—
1515202
—
TN
Enumeration date
09/03/2009
Last updated
11/11/2009
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