Provider Demographics
NPI:1194004192
Name:ASHLOCK, GEORGINA (PHD)
Entity Type:Individual
Prefix:
First Name:GEORGINA
Middle Name:
Last Name:ASHLOCK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:GEORGINA
Other - Middle Name:
Other - Last Name:TOTTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3800 S NATIONAL AVE STE 770
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5283
Practice Address - Country:US
Practice Address - Phone:417-269-6891
Practice Address - Fax:417-269-5595
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01703103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist