Provider Demographics
NPI:1013643527
Name:CROCKER, MARA JUDITH
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:JUDITH
Last Name:CROCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2986 CARRIE DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2818
Mailing Address - Country:US
Mailing Address - Phone:678-698-1611
Mailing Address - Fax:
Practice Address - Street 1:2986 CARRIE DR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2818
Practice Address - Country:US
Practice Address - Phone:678-698-1611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician