MEDICARE: MRS. CELINE MEDLOCK LMFT

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	101YP2500X	Professional Counselor	200886	TX

General Provider Information

NPI Number	:	1811286065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CELINE MEDLOCK LMFT

Provider Business Mailing Address
First Line	:	11511 KATY FWY
Second Line	:	SUITE 410
City	:	HOUSTON
State	:	TX
Zip	:	77079-1903
Country	:	US
Telephone Number	:	713-828-0593
Fax Number	:	713-784-4040

Provider Business Practice Location Address
First Line	:	11511 KATY FWY
Second Line	:	SUITE 410
City	:	HOUSTON
State	:	TX
Zip	:	77079-1903
Country	:	US
Telephone Number	:	713-828-0593
Fax Number	:	713-784-4040

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

Provider Enumeration Date	:	03/28/2011
Last Update Date	:	03/28/2011

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