Provider Demographics
NPI:1598499360
Name:LOCKLEAR, TINA (LCAS-A)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:
Last Name:LOCKLEAR
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 LOCKLEAR ROAD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372
Mailing Address - Country:US
Mailing Address - Phone:910-827-2647
Mailing Address - Fax:
Practice Address - Street 1:1123 LOCKLEAR RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-7239
Practice Address - Country:US
Practice Address - Phone:910-827-2647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-27456101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)