Provider Demographics
NPI:1689181869
Name:CARLOCK, DION
Entity Type:Individual
Prefix:MR
First Name:DION
Middle Name:
Last Name:CARLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 LINDSTROM DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80911-3341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 BOULDER CRESCENT ST STE 101E
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3344
Practice Address - Country:US
Practice Address - Phone:719-321-0956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC0106079101YM0800X
CO2063061041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health