Provider Demographics
NPI:1043749088
Name:GLOCK, CAROLYN R (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:R
Last Name:GLOCK
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46581-0751
Mailing Address - Country:US
Mailing Address - Phone:574-834-1393
Mailing Address - Fax:833-527-8322
Practice Address - Street 1:225 N. MAIN ST. SUITE 5
Practice Address - Street 2:
Practice Address - City:NORTH WEBSTER
Practice Address - State:IN
Practice Address - Zip Code:46555-0751
Practice Address - Country:US
Practice Address - Phone:574-834-1393
Practice Address - Fax:833-527-8322
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003556A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health