Provider Demographics
NPI:1154586360
Name:POULOS, KATHERINE HEEKS (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:HEEKS
Last Name:POULOS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 PLUM ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-6207
Mailing Address - Country:US
Mailing Address - Phone:540-986-5043
Mailing Address - Fax:
Practice Address - Street 1:1420 3RD ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-5205
Practice Address - Country:US
Practice Address - Phone:540-613-7047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0060391041C0700X
VA09040096591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical