Provider Demographics
NPI:1396116174
Name:LOCKE, COLBY CHARLES (BS)
Entity type:Individual
Prefix:
First Name:COLBY
Middle Name:CHARLES
Last Name:LOCKE
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1471 W ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2950
Mailing Address - Country:US
Mailing Address - Phone:603-662-9886
Mailing Address - Fax:
Practice Address - Street 1:1025 E 7TH ST
Practice Address - Street 2:#111
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-7109
Practice Address - Country:US
Practice Address - Phone:812-855-1561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer