Provider Demographics
NPI:1831291756
Name:LOCKE, LAURIE BENOLD (MA LPC)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:BENOLD
Last Name:LOCKE
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W 9TH STREET
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626
Mailing Address - Country:US
Mailing Address - Phone:512-868-0066
Mailing Address - Fax:
Practice Address - Street 1:404 W 9TH STREET
Practice Address - Street 2:SUITE 104
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626
Practice Address - Country:US
Practice Address - Phone:512-868-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17951103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1698615Q1Medicaid