Provider Demographics
NPI:1851831432
Name:TEDLOCK, VIRGINIA (LPC)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:TEDLOCK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:394006 E LL50 RD
Mailing Address - Street 2:
Mailing Address - City:WELEETKA
Mailing Address - State:OK
Mailing Address - Zip Code:74880
Mailing Address - Country:US
Mailing Address - Phone:918-652-1643
Mailing Address - Fax:
Practice Address - Street 1:1904 GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-8603
Practice Address - Country:US
Practice Address - Phone:405-273-2157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1965101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional