Healthcare Provider Details

I. General information

NPI: 1164888228
Provider Name (Legal Business Name): LAURA POOLE PHD, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15118 EAGLE GROVE ST
SAN ANTONIO TX
78232-3903
US

IV. Provider business mailing address

15118 EAGLE GROVE ST
SAN ANTONIO TX
78232-3903
US

V. Phone/Fax

Practice location:
  • Phone: 210-350-7991
  • Fax: 210-598-0468
Mailing address:
  • Phone: 210-350-7991
  • Fax: 210-598-0468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12685
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: