Provider Demographics
NPI:1639558802
Name:LOCKLEAR, KRISTIN IVEY (MSW, LCSWA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:IVEY
Last Name:LOCKLEAR
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 GOVERNORS RD SE
Mailing Address - Street 2:
Mailing Address - City:WINNABOW
Mailing Address - State:NC
Mailing Address - Zip Code:28479-5123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:721 GOVERNORS RD SE
Practice Address - Street 2:
Practice Address - City:WINNABOW
Practice Address - State:NC
Practice Address - Zip Code:28479-5123
Practice Address - Country:US
Practice Address - Phone:910-612-5702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0079041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical