=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588038814
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARISSA LOCK M.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2015
-----------------------------------------------------
Last Update Date | 11/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 652 COUNTY ROAD 180
-----------------------------------------------------
City | CARTHAGE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64836-7625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-359-7085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 710 LYON ST
-----------------------------------------------------
City | CARTHAGE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64836-1700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-359-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 2014018049
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------