Basic Information
| Provider Information | |||||||||
| NPI: | 1376196238 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLE | ||||||||
| FirstName: | WILLIE | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 FAIRGROUNDS RD APT I2 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387037839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6625922451 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1502 S COLORADO ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387037219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623329872 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2019 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C7780 | MS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.