Healthcare Provider Details

I. General information

NPI: 1831018209
Provider Name (Legal Business Name): LOGAN MICHAEL LOCKLEAR LCSWA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 PINE TREE LN
RAEFORD NC
28376-2430
US

IV. Provider business mailing address

193 PINE TREE LN
RAEFORD NC
28376-2430
US

V. Phone/Fax

Practice location:
  • Phone: 910-583-2480
  • Fax: 910-875-5008
Mailing address:
  • Phone: 910-583-2480
  • Fax: 910-875-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP024036
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: