=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770710733
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDA MOORE LOCKLEAR LCAS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2009
-----------------------------------------------------
Last Update Date | 06/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 402 N PINE ST SUITE D
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28358-5584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-738-2110
-----------------------------------------------------
Fax | 910-738-2988
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2590
-----------------------------------------------------
City | PEMBROKE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28372-2590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-521-2900
-----------------------------------------------------
Fax | 910-272-1650
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 1422
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------