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General NPI Number Information
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NPI Number | 1952515199
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Entity Type | Organization
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Legal Business Name | INGLESIDE COUNSELING RESOURCES
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Dates
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Enumeration Date | 05/09/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 277 PIERCE AVE
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City | MACON
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State | GA
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Zip | 31204-2419
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Country | US
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Telephone | 478-755-0060
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Fax | 478-743-3508
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Provider Business Mailing Address
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Address Line | 277 PIERCE AVE
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City | MACON
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State | GA
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Zip | 31204-2419
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Country | US
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Telephone | 478-755-0060
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Fax | 478-743-3508
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARION M LOCKWOOD
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Credential | PH.D
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Telephone | 478-755-0060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1976
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License Number State | GA
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