1437429677 NPI number — MRS. KHIDHRA SMITH POOLE LCSW

Table of content: MRS. KHIDHRA SMITH POOLE LCSW (NPI 1437429677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437429677 NPI number — MRS. KHIDHRA SMITH POOLE LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POOLE
Provider First Name:
KHIDHRA
Provider Middle Name:
SMITH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437429677
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2025 EAST MAIN STREET
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-225-0749
Provider Business Mailing Address Fax Number:
804-225-0753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2025 EAST MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-225-0749
Provider Business Practice Location Address Fax Number:
804-225-0753
Provider Enumeration Date:
01/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  0904007802 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1437429677 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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