Provider Demographics
NPI:1053912162
Name:POOLE, CHANEL MARIE (LMT)
Entity type:Individual
Prefix:MS
First Name:CHANEL
Middle Name:MARIE
Last Name:POOLE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 ABBOTT RD STE 230
Mailing Address - Street 2:
Mailing Address - City:LACKAWANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14218-1946
Mailing Address - Country:US
Mailing Address - Phone:716-473-2404
Mailing Address - Fax:
Practice Address - Street 1:1234 ABBOTT RD STE 230
Practice Address - Street 2:
Practice Address - City:LACKAWANNA
Practice Address - State:NY
Practice Address - Zip Code:14218-1946
Practice Address - Country:US
Practice Address - Phone:716-242-8588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032328225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty