Provider Demographics
NPI:1467162065
Name:LOCKLEAR, BENNY JR (LCSWA)
Entity type:Individual
Prefix:
First Name:BENNY
Middle Name:
Last Name:LOCKLEAR
Suffix:JR
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 E LONG AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2540
Mailing Address - Country:US
Mailing Address - Phone:980-416-3023
Mailing Address - Fax:980-448-3419
Practice Address - Street 1:432 E LONG AVE STE 2
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2540
Practice Address - Country:US
Practice Address - Phone:980-416-3025
Practice Address - Fax:980-448-3419
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NCP0185171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1467162065Medicaid
NC1639806359Medicaid