Provider Demographics
NPI:1114396397
Name:LOCKE, MATTIE LOUISE
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:LOUISE
Last Name:LOCKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 FM 2972 W
Mailing Address - Street 2:
Mailing Address - City:RUSK
Mailing Address - State:TX
Mailing Address - Zip Code:75785-3666
Mailing Address - Country:US
Mailing Address - Phone:903-683-5781
Mailing Address - Fax:
Practice Address - Street 1:379 FM 2972 W
Practice Address - Street 2:
Practice Address - City:RUSK
Practice Address - State:TX
Practice Address - Zip Code:75785-3666
Practice Address - Country:US
Practice Address - Phone:903-683-5781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX218376364SP0808X
TX106908364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health