Provider Demographics
NPI:1790382661
Name:LOCKHART, MIA CHEYENNE
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:CHEYENNE
Last Name:LOCKHART
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 1:4470 SPANISH TRL APT 65
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-4906
Mailing Address - Country:US
Mailing Address - Phone:850-225-9064
Mailing Address - Fax:
Practice Address - Street 1:1300 N PALAFOX ST STE 103
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-2678
Practice Address - Country:US
Practice Address - Phone:850-266-2797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1115871041C0700X
FL147701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical