Provider Demographics
NPI:1689823577
Name:POOLE, KERMIT MAURICE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KERMIT
Middle Name:MAURICE
Last Name:POOLE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:KERMIT
Other - Middle Name:MAURICE
Other - Last Name:POOLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:300 VEAZEY ROAD
Mailing Address - Street 2:
Mailing Address - City:BUTNER
Mailing Address - State:NC
Mailing Address - Zip Code:27509-1626
Mailing Address - Country:US
Mailing Address - Phone:919-764-2215
Mailing Address - Fax:919-764-5296
Practice Address - Street 1:300 VEAZEY ROAD
Practice Address - Street 2:
Practice Address - City:BUTNER
Practice Address - State:NC
Practice Address - Zip Code:27509-1626
Practice Address - Country:US
Practice Address - Phone:919-764-5331
Practice Address - Fax:919-764-2274
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0094511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical