Provider Demographics
NPI:1427605419
Name:MEDLOCK, KAREN MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:MARIE
Last Name:MEDLOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 FM 1130
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77632-1081
Mailing Address - Country:US
Mailing Address - Phone:409-779-2279
Mailing Address - Fax:409-330-4362
Practice Address - Street 1:10100 FM 1130
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77632-1081
Practice Address - Country:US
Practice Address - Phone:409-779-2279
Practice Address - Fax:409-330-4362
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11221104100000X
TX52974104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker