Provider Demographics
NPI:1871647123
Name:MATLOCK, JULIE
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:
Last Name:MATLOCK
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 1:3015 E EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-4776
Mailing Address - Country:US
Mailing Address - Phone:317-908-2714
Mailing Address - Fax:317-787-1959
Practice Address - Street 1:3015 E EDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-4776
Practice Address - Country:US
Practice Address - Phone:317-908-2714
Practice Address - Fax:317-787-1959
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003054A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist