Provider Demographics
NPI:1134344823
Name:MARY E LOCKE PHD HSPP LLC
Entity type:Organization
Organization Name:MARY E LOCKE PHD HSPP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD HSPP
Authorized Official - Phone:317-272-1838
Mailing Address - Street 1:7337 W JEFFERSON BLVD STE 175
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6286
Mailing Address - Country:US
Mailing Address - Phone:317-272-1838
Mailing Address - Fax:317-272-0072
Practice Address - Street 1:7337 W JEFFERSON BLVD STE 175
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6286
Practice Address - Country:US
Practice Address - Phone:317-272-1838
Practice Address - Fax:317-272-0072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040180103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN220850Medicare ID - Type Unspecified