Provider Demographics
NPI:1508157322
Name:LOCKNANE, MISTY (LCDC)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:LOCKNANE
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 CENTRAL DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4200
Mailing Address - Country:US
Mailing Address - Phone:432-614-5720
Mailing Address - Fax:877-729-4033
Practice Address - Street 1:855 CENTRAL DR
Practice Address - Street 2:SUITE 2
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4200
Practice Address - Country:US
Practice Address - Phone:432-614-5720
Practice Address - Fax:877-729-4033
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11270101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)