Provider Demographics
NPI:1558324020
Name:MEDLOCK, VELVET V (MSPT)
Entity Type:Individual
Prefix:
First Name:VELVET
Middle Name:V
Last Name:MEDLOCK
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:VELVET
Other - Middle Name:V
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:PO BOX 11122
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1122
Mailing Address - Country:US
Mailing Address - Phone:479-452-7773
Mailing Address - Fax:479-452-7774
Practice Address - Street 1:5905 REMINGTON CIR
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-6523
Practice Address - Country:US
Practice Address - Phone:479-452-7773
Practice Address - Fax:479-452-7774
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1835225100000X
OK4397225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136730742Medicaid
AR136730742Medicaid