Provider Demographics
NPI:1174295414
Name:POOLE, DYMOND
Entity Type:Individual
Prefix:
First Name:DYMOND
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 1:3530 EWALD CIR
Mailing Address - Street 2:APT 8A
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204
Mailing Address - Country:US
Mailing Address - Phone:313-556-6909
Mailing Address - Fax:
Practice Address - Street 1:19853 OUTER DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124
Practice Address - Country:US
Practice Address - Phone:248-463-8551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP400159074599Medicaid