Provider Demographics
NPI:1679180947
Name:LOCKETT, MARCUS
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:LOCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARCUS
Other - Middle Name:
Other - Last Name:LOCKETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPTA
Mailing Address - Street 1:933 REDA CT
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-1906
Mailing Address - Country:US
Mailing Address - Phone:216-905-4696
Mailing Address - Fax:
Practice Address - Street 1:5835 CAMPBELLTON RD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-8013
Practice Address - Country:US
Practice Address - Phone:404-458-6139
Practice Address - Fax:678-550-9066
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004424225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant