Provider Demographics
NPI:1073665394
Name:POOLE, KATHLEEN THERESA (MS, LAC)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:THERESA
Last Name:POOLE
Suffix:
Gender:F
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3644
Mailing Address - Country:US
Mailing Address - Phone:860-448-6766
Mailing Address - Fax:860-449-6754
Practice Address - Street 1:2440 GOLD STAR HWY UNIT 101
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-1180
Practice Address - Country:US
Practice Address - Phone:860-448-6766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2024-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTACT0012OtherHEALTHNET LANDMARK