Provider Demographics
NPI:1427655117
Name:POOLE, KELLY (LMHC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:POOLE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PATERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07432-1829
Mailing Address - Country:US
Mailing Address - Phone:201-213-8212
Mailing Address - Fax:
Practice Address - Street 1:11 PATERSON AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07432-1829
Practice Address - Country:US
Practice Address - Phone:201-213-8212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2024-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010737101YM0800X
NJ37PC00890200106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health