Provider Demographics
NPI:1376101592
Name:POOLE, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
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 1:4599 COPPERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:MD
Mailing Address - Zip Code:21755-8241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4599 COPPERFIELD DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:MD
Practice Address - Zip Code:21755-8241
Practice Address - Country:US
Practice Address - Phone:240-409-0184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD42303929600Medicaid