Provider Demographics
NPI:1063844173
Name:MEDLOCK, CAROLINE ANN (BCBA)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:ANN
Last Name:MEDLOCK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 DOE RUN DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLINVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08322-3713
Mailing Address - Country:US
Mailing Address - Phone:856-694-5212
Mailing Address - Fax:
Practice Address - Street 1:30 DOE RUN DR
Practice Address - Street 2:
Practice Address - City:FRANKLINVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08322-3713
Practice Address - Country:US
Practice Address - Phone:856-694-5212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ11312962103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst