Provider Demographics
NPI:1003341199
Name:POOLE, CHANTRESS
Entity Type:Individual
Prefix:
First Name:CHANTRESS
Middle Name:
Last Name:POOLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2319 CENTENNIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-3215
Mailing Address - Country:US
Mailing Address - Phone:352-361-3417
Mailing Address - Fax:
Practice Address - Street 1:2319 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3215
Practice Address - Country:US
Practice Address - Phone:352-361-3417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services