Provider Demographics
NPI:1306712039
Name:CARLOCK, MEGAN (MA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:CARLOCK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 QUAIL HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-8955
Mailing Address - Country:US
Mailing Address - Phone:510-502-5959
Mailing Address - Fax:
Practice Address - Street 1:1800 HWY 116 N
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-2607
Practice Address - Country:US
Practice Address - Phone:510-502-5959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-10
Last Update Date:2025-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner