Provider Demographics
NPI:1447721923
Name:POOLE, LYDIA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:POOLE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 PARKWAY ST W
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-6410
Mailing Address - Country:US
Mailing Address - Phone:864-420-6820
Mailing Address - Fax:
Practice Address - Street 1:3512 GODWIN CT STE A
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36693-2526
Practice Address - Country:US
Practice Address - Phone:251-517-0355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4423235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist