Provider Demographics
NPI:1730551821
Name:LOCKE-JOHNSON, CHRISTELLE
Entity type:Individual
Prefix:
First Name:CHRISTELLE
Middle Name:
Last Name:LOCKE-JOHNSON
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 1:91 WHEELER CLINIC
Mailing Address - Street 2:91 NORTHWEST DRIVE
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062
Mailing Address - Country:US
Mailing Address - Phone:888-793-3500
Mailing Address - Fax:860-793-3520
Practice Address - Street 1:91 WHEELER CLINIC
Practice Address - Street 2:91 NORTHWEST DRIVE
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062
Practice Address - Country:US
Practice Address - Phone:888-793-3500
Practice Address - Fax:860-793-3520
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001017101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)