1336343664 NPI number — TERESA A. POOLE, PH.D., PA

Table of content: (NPI 1336343664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336343664 NPI number — TERESA A. POOLE, PH.D., PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERESA A. POOLE, PH.D., PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1336343664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
692 N SPENCE AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
GOLDSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27534-4339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-778-8757
Provider Business Mailing Address Fax Number:
919-778-8758

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
692 N SPENCE AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
GOLDSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27534-4339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-778-8757
Provider Business Practice Location Address Fax Number:
919-778-8758
Provider Enumeration Date:
06/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
POOLE
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
LICENSED PSYCHOLOGIST
Authorized Official Telephone Number:
919-778-8757

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6000096 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0473E . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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