Provider Demographics
NPI:1568461291
Name:MEDLOCK, LINDA (LPC)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:MEDLOCK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:
Other - Last Name:GILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1023 EXECUTIVE PARKWAY DR
Mailing Address - Street 2:STE 8
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6323
Mailing Address - Country:US
Mailing Address - Phone:314-878-7755
Mailing Address - Fax:314-434-2331
Practice Address - Street 1:1023 EXECUTIVE PARKWAY DR
Practice Address - Street 2:STE 8
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6323
Practice Address - Country:US
Practice Address - Phone:314-878-8855
Practice Address - Fax:314-434-2331
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001986101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional