Provider Demographics
NPI:1356589352
Name:POORE-CONROY, CHARLA ANN (LMHC)
Entity type:Individual
Prefix:MRS
First Name:CHARLA
Middle Name:ANN
Last Name:POORE-CONROY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MRS
Other - First Name:CHARLA
Other - Middle Name:ANN
Other - Last Name:POORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:1403 GOLDEN SQUIRREL WAY
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-5555
Mailing Address - Country:US
Mailing Address - Phone:813-654-4935
Mailing Address - Fax:
Practice Address - Street 1:13000 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4745
Practice Address - Country:US
Practice Address - Phone:813-972-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6991101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist