Healthcare Provider Details

I. General information

NPI: 1295073567
Provider Name (Legal Business Name): MS. REBECCA ROYANN POOLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2013
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 GRAND ST
ANNA IL
62906-1909
US

IV. Provider business mailing address

213 GRAND ST
ANNA IL
62906-1909
US

V. Phone/Fax

Practice location:
  • Phone: 618-614-2491
  • Fax:
Mailing address:
  • Phone: 618-614-2491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: