Healthcare Provider Details

I. General information

NPI: 1235251422
Provider Name (Legal Business Name): MARY V POORE L.C.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 EAGLES WALK SUITE F
STOCKBRIDGE GA
30281-6342
US

IV. Provider business mailing address

155 EAGLES WALK SUITE F
STOCKBRIDGE GA
30281-6342
US

V. Phone/Fax

Practice location:
  • Phone: 770-389-8100
  • Fax: 770-389-3030
Mailing address:
  • Phone: 770-389-8100
  • Fax: 770-389-3030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW001749
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: