Provider Demographics
NPI:1447499256
Name:POOLE, MISTY C (MSW,LSW)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:C
Last Name:POOLE
Suffix:
Gender:F
Credentials:MSW,LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 FARABEE DR N STE C
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5933
Mailing Address - Country:US
Mailing Address - Phone:765-412-9267
Mailing Address - Fax:
Practice Address - Street 1:115 FARABEE DR N STE C
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5933
Practice Address - Country:US
Practice Address - Phone:765-412-9267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99036186A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical