Provider Demographics
NPI:1437429677
Name:POOLE, KHIDHRA SMITH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KHIDHRA
Middle Name:SMITH
Last Name:POOLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 EAST MAIN STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223
Mailing Address - Country:US
Mailing Address - Phone:804-225-0749
Mailing Address - Fax:804-225-0753
Practice Address - Street 1:2025 EAST MAIN STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223
Practice Address - Country:US
Practice Address - Phone:804-225-0749
Practice Address - Fax:804-225-0753
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040078021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437429677Medicaid