Provider Demographics
NPI:1639420474
Name:LOCKE, MIKAYLA ELYSE
Entity Type:Individual
Prefix:MS
First Name:MIKAYLA
Middle Name:ELYSE
Last Name:LOCKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 COOLIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01887-1408
Mailing Address - Country:US
Mailing Address - Phone:978-821-7202
Mailing Address - Fax:
Practice Address - Street 1:5 COOLIDGE ROAD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:MA
Practice Address - Zip Code:01887-1408
Practice Address - Country:US
Practice Address - Phone:978-821-7202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS87028062101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor