Provider Demographics
NPI:1417111535
Name:MEDLOCK, GEORGETTA MARIE (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:GEORGETTA
Middle Name:MARIE
Last Name:MEDLOCK
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5619 MAVERICK BEND LN
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-5096
Mailing Address - Country:US
Mailing Address - Phone:713-876-2267
Mailing Address - Fax:
Practice Address - Street 1:5619 MAVERICK BEND LN
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-5096
Practice Address - Country:US
Practice Address - Phone:713-876-2267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61268101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional