Healthcare Provider Details

I. General information

NPI: 1184252819
Provider Name (Legal Business Name): CHRISTINA M. POOLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 SHADY PINES CT
FOUNTAIN INN SC
29644-9785
US

IV. Provider business mailing address

409 WINDWOOD ST
SIMPSONVILLE SC
29680-6586
US

V. Phone/Fax

Practice location:
  • Phone: 644-089-5098
  • Fax:
Mailing address:
  • Phone: 864-680-3047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5358
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5537
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: