Provider Demographics
NPI:1790318400
Name:POOLE, JUDITH (LMT)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:POOLE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10231 VILLA DEL LAGO
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-1671
Mailing Address - Country:US
Mailing Address - Phone:210-254-6181
Mailing Address - Fax:
Practice Address - Street 1:10919 CULEBRA RD STE 112
Practice Address - Street 2:ROOM 5
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253
Practice Address - Country:US
Practice Address - Phone:210-428-5228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115436225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty