Provider Demographics
NPI:1578054672
Name:LOCKLEAR, DEBRA
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:
Last Name:LOCKLEAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2159 PEPPERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-1734
Mailing Address - Country:US
Mailing Address - Phone:630-924-4948
Mailing Address - Fax:
Practice Address - Street 1:2159 PEPPERWOOD LN
Practice Address - Street 2:
Practice Address - City:GLENDALE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60139-1734
Practice Address - Country:US
Practice Address - Phone:630-924-4948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17-41410106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician