Provider Demographics
NPI:1376100792
Name:LOCKHART, LARRY
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:LOCKHART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CROSS STREET
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44311-1026
Mailing Address - Country:US
Mailing Address - Phone:330-996-9141
Mailing Address - Fax:330-253-0377
Practice Address - Street 1:150 CROSS STREET
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44311-1026
Practice Address - Country:US
Practice Address - Phone:330-996-9141
Practice Address - Fax:330-253-0377
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.171401101YA0400X
OH171M00000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2847709Medicaid