Provider Demographics
NPI:1760419725
Name:POOLE, KELLY JAY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:JAY
Last Name:POOLE
Suffix:
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:PO BOX 814
Mailing Address - Street 2:
Mailing Address - City:RANDLEMAN
Mailing Address - State:NC
Mailing Address - Zip Code:27317-0814
Mailing Address - Country:US
Mailing Address - Phone:336-495-2700
Mailing Address - Fax:336-495-5552
Practice Address - Street 1:4270 HEATH DAIRY RD
Practice Address - Street 2:
Practice Address - City:RANDLEMAN
Practice Address - State:NC
Practice Address - Zip Code:27317-7489
Practice Address - Country:US
Practice Address - Phone:336-495-2700
Practice Address - Fax:336-495-5552
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0011201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002280Medicaid
NC2864666BMedicare ID - Type Unspecified