Basic Information
| Provider Information | |||||||||
| NPI: | 1760607006 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOCKLEAR | ||||||||
| FirstName: | ALTON | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13097 US HIGHWAY 301 N | ||||||||
| Address2: | |||||||||
| City: | SAINT PAULS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283846934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102735242 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1329 ROBESON ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104380939 | ||||||||
| FaxNumber: | 9104380942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C001849 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6106228 | 05 | NC | MEDICAID |