Provider Demographics
NPI:1194854018
Name:MEDLOCK, ANGELA DELON (LMSW)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:DELON
Last Name:MEDLOCK
Suffix:
Gender:
Credentials:LMSW
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:457 ROLAND ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-2372
Mailing Address - Country:US
Mailing Address - Phone:248-592-7504
Mailing Address - Fax:
Practice Address - Street 1:114 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-2244
Practice Address - Country:US
Practice Address - Phone:248-858-7766
Practice Address - Fax:248-858-7201
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801090802104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1883825Medicaid