Provider Demographics
NPI:1922846260
Name:POOLE, STACY LYNN
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:POOLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 HEATHERBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:CACHE
Mailing Address - State:OK
Mailing Address - Zip Code:73527-7715
Mailing Address - Country:US
Mailing Address - Phone:657-378-5862
Mailing Address - Fax:
Practice Address - Street 1:1302 HOMESTEAD DR
Practice Address - Street 2:STE G
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505
Practice Address - Country:US
Practice Address - Phone:714-477-4605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)