Provider Demographics
NPI:1780786921
Name:POOLER, MARK A (LICSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:POOLER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 NEWBURY ST
Mailing Address - Street 2:SUITE 42
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-2833
Mailing Address - Country:US
Mailing Address - Phone:617-894-0576
Mailing Address - Fax:
Practice Address - Street 1:305 NEWBURY ST
Practice Address - Street 2:SUITE 42
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-2833
Practice Address - Country:US
Practice Address - Phone:617-894-0576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10303431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO P22795Medicare ID - Type UnspecifiedPART B PROVIDER NUMBER