Provider Demographics
NPI:1376196238
Name:POLE, WILLIE ANDREW JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:ANDREW
Last Name:POLE
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 FAIRGROUNDS RD APT I2
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-7839
Mailing Address - Country:US
Mailing Address - Phone:662-592-2451
Mailing Address - Fax:
Practice Address - Street 1:1502 S COLORADO ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7219
Practice Address - Country:US
Practice Address - Phone:662-332-9872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC77801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical