Healthcare Provider Details

I. General information

NPI: 1366793309
Provider Name (Legal Business Name): CHARDONNAY NICOLE POOLE PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 WESTERN TRAILS BLVD STE 202
AUSTIN TX
78745-1647
US

IV. Provider business mailing address

2222 WESTERN TRAILS BLVD STE 202
AUSTIN TX
78745-1647
US

V. Phone/Fax

Practice location:
  • Phone: 512-448-3221
  • Fax:
Mailing address:
  • Phone: 512-448-3221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number36008
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: