Provider Demographics
NPI:1902535073
Name:POOLA-OR, CHINNACHART
Entity Type:Individual
Prefix:
First Name:CHINNACHART
Middle Name:
Last Name:POOLA-OR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2141 32ND ST # 2R
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2344
Mailing Address - Country:US
Mailing Address - Phone:917-647-8012
Mailing Address - Fax:
Practice Address - Street 1:276 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4509
Practice Address - Country:US
Practice Address - Phone:212-920-1976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP115493101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health