Basic Information
| Provider Information | |||||||||
| NPI: | 1275024911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOCKLEAR | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | BLUE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLUE | ||||||||
| OtherFirstName: | TARA | ||||||||
| OtherMiddleName: | JO | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2003 GODWIN AVENUE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283583149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107398849 | ||||||||
| FaxNumber: | 9107398698 | ||||||||
| Practice Location | |||||||||
| Address1: | 2003 GODWIN AVENUE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283583149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107398849 | ||||||||
| FaxNumber: | 9107398698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2018 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | PO16917 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.