Provider Demographics
NPI:1164888228
Name:POOLE, LAURA (PHD, LPC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:POOLE
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15118 EAGLE GROVE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-3903
Mailing Address - Country:US
Mailing Address - Phone:210-350-7991
Mailing Address - Fax:210-598-0468
Practice Address - Street 1:15118 EAGLE GROVE ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-3903
Practice Address - Country:US
Practice Address - Phone:210-350-7991
Practice Address - Fax:210-598-0468
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12685101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX359392303Medicaid