Provider Demographics
NPI:1467162065
Name:LOCKLEAR, BENNY JR (LCSWA)
Entity Type:Individual
Prefix:
First Name:BENNY
Middle Name:
Last Name:LOCKLEAR
Suffix:JR
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 OLD COURSE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-1333
Mailing Address - Country:US
Mailing Address - Phone:910-690-8033
Mailing Address - Fax:
Practice Address - Street 1:106 W DALLAS RD
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:NC
Practice Address - Zip Code:28164-2103
Practice Address - Country:US
Practice Address - Phone:980-416-3025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0185171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1467162065Medicaid
NC1639806359Medicaid