Provider Demographics
NPI:1902904295
Name:CARLOCK, CHARLENE JESSE (PHD)
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:JESSE
Last Name:CARLOCK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:C
Other - Middle Name:JESSE
Other - Last Name:CARLOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1105 WATERVLIET AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420
Mailing Address - Country:US
Mailing Address - Phone:937-256-0500
Mailing Address - Fax:937-256-2136
Practice Address - Street 1:1105 WATERVLIET AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420
Practice Address - Country:US
Practice Address - Phone:937-256-0500
Practice Address - Fax:937-256-2136
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2754103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000395770OtherANTHEM
CACP08283Medicare PIN
000000395770OtherANTHEM