Provider Demographics
NPI:1639806359
Name:ETHOS SERVICES
Entity type:Organization
Organization Name:ETHOS SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKLEAR
Authorized Official - Suffix:JR
Authorized Official - Credentials:MSW
Authorized Official - Phone:910-964-0678
Mailing Address - Street 1:432 EAST LONG AVENUE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2540
Mailing Address - Country:US
Mailing Address - Phone:980-416-3025
Mailing Address - Fax:980-448-3419
Practice Address - Street 1:432 E LONG AVE STE 2
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2540
Practice Address - Country:US
Practice Address - Phone:980-416-3025
Practice Address - Fax:980-448-3419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-03
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1639806359Medicaid
NC1467162065Medicaid