Provider Demographics
NPI:1730423393
Name:BOOTH, TRAVIS ANDREW (MA, LCPC)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:ANDREW
Last Name:BOOTH
Suffix:
Gender:M
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 CHURCH ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3624
Mailing Address - Country:US
Mailing Address - Phone:847-492-1938
Mailing Address - Fax:847-423-5670
Practice Address - Street 1:1007 CHURCH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3624
Practice Address - Country:US
Practice Address - Phone:847-492-1938
Practice Address - Fax:847-423-5670
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.008592101YP2500X
IL180.009981101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPHCP058737OtherPHILADELPHIA INDEMNITY INSURANCE COMPANY