Provider Demographics
NPI:1699468074
Name:LOCKLEAR, CODY LEE
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:LEE
Last Name:LOCKLEAR
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 1:45 CARLA RD
Mailing Address - Street 2:
Mailing Address - City:ROWLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28383-8065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:753 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-3238
Practice Address - Country:US
Practice Address - Phone:910-490-2037
Practice Address - Fax:910-479-1711
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0212401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty