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General NPI Number Information
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NPI Number | 1134344823
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Entity Type | Organization
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Legal Business Name | MARY E LOCKE PHD HSPP LLC
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Dates
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Enumeration Date | 04/16/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 7337 W JEFFERSON BLVD STE 175
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City | FORT WAYNE
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State | IN
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Zip | 46804-6286
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Country | US
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Telephone | 317-272-1838
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Fax | 317-272-0072
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Provider Business Mailing Address
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Address Line | 7337 W JEFFERSON BLVD STE 175
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City | FORT WAYNE
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State | IN
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Zip | 46804-6286
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Country | US
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Telephone | 317-272-1838
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Fax | 317-272-0072
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Authorized Official
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Title or Position | PRES
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Name | MARY E LOCKE
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Credential | PHD HSPP
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Telephone | 317-272-1838
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 20040180
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License Number State | IN
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