Healthcare Provider Details

I. General information

NPI: 1346972270
Provider Name (Legal Business Name): AUDRE K MEDLOCK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14040 N CAVE CREEK RD # 108
PHOENIX AZ
85022-6117
US

IV. Provider business mailing address

23380 N 61ST DR
GLENDALE AZ
85310-5748
US

V. Phone/Fax

Practice location:
  • Phone: 602-358-7073
  • Fax: 888-927-0409
Mailing address:
  • Phone: 602-358-7073
  • Fax: 888-927-0409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-19716
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: