Provider Demographics
NPI:1679221584
Name:LOCKETT, WALLACE
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:
Last Name:LOCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17325 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112-1247
Mailing Address - Country:US
Mailing Address - Phone:440-753-1444
Mailing Address - Fax:
Practice Address - Street 1:1621 MEDINA RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-5333
Practice Address - Country:US
Practice Address - Phone:330-241-4365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator