Provider Demographics
NPI:1790757698
Name:POOLE, TERESA A (PHD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:A
Last Name:POOLE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:692 N SPENCE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-4339
Mailing Address - Country:US
Mailing Address - Phone:919-778-8757
Mailing Address - Fax:919-778-8758
Practice Address - Street 1:692 N SPENCE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-4339
Practice Address - Country:US
Practice Address - Phone:919-778-8757
Practice Address - Fax:919-778-8758
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1791103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0473EOtherBLUE CROSS BLUE SHIELD
NCE1424OtherMEDCOST
NC6000096Medicaid
NCE1424OtherMEDCOST