Provider Demographics
NPI:1700527934
Name:LOCKLEAR, BETH
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:LOCKLEAR
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 1:111 VONDY RD
Mailing Address - Street 2:
Mailing Address - City:MAXTON
Mailing Address - State:NC
Mailing Address - Zip Code:28364-9049
Mailing Address - Country:US
Mailing Address - Phone:910-775-9547
Mailing Address - Fax:
Practice Address - Street 1:110 W 3RD ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-7016
Practice Address - Country:US
Practice Address - Phone:910-775-9547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-03
Last Update Date:2022-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC05939225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty