Basic Information
Provider Information | |||||||||
NPI: | 1003287665 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POOLE-SEYMOUR | ||||||||
FirstName: | DWAYNE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SEYMOUR | ||||||||
OtherFirstName: | DWAYNE | ||||||||
OtherMiddleName: | POOLE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 931 LENOX RD | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112032617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7185516723 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 154 W 127TH ST | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100273739 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2127493507 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/08/2015 | ||||||||
LastUpdateDate: | 10/08/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 102L00000X | 090313 | NY | N |   | Behavioral Health & Social Service Providers | Psychoanalyst |   | 104100000X | 090313 | NY | Y |   | Behavioral Health & Social Service Providers | Social Worker |   | 106H00000X | 090313 | NY | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.