Provider Demographics
NPI:1386470748
Name:POOLE, DAWN RENEE (ME, EDS)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:RENEE
Last Name:POOLE
Suffix:
Gender:F
Credentials:ME, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-2012
Mailing Address - Country:US
Mailing Address - Phone:765-772-4700
Mailing Address - Fax:765-772-4775
Practice Address - Street 1:1801 S 18TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-2011
Practice Address - Country:US
Practice Address - Phone:765-772-4700
Practice Address - Fax:765-772-4713
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1410699103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool