MEDICARE: MS. CHARLENE JESSE CARLOCK PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	2754	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000395770	OTHER		ANTHEM

General Provider Information

NPI Number	:	1902904295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHARLENE JESSE CARLOCK PHD

Provider Business Mailing Address
First Line	:	1105 WATERVLIET AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45420
Country	:	US
Telephone Number	:	937-256-0500
Fax Number	:	937-256-2136

Provider Business Practice Location Address
First Line	:	1105 WATERVLIET AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45420
Country	:	US
Telephone Number	:	937-256-0500
Fax Number	:	937-256-2136

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	02/18/2008

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