Provider Demographics
NPI:1033209341
Name:CROCKETT, ROBERTA (MA, LMFT, LCPC)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:MA, LMFT, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-3531
Mailing Address - Country:US
Mailing Address - Phone:208-345-1022
Mailing Address - Fax:208-433-1407
Practice Address - Street 1:1407 N 13TH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-3531
Practice Address - Country:US
Practice Address - Phone:208-345-1022
Practice Address - Fax:208-433-1407
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-238101YM0800X
IDLMFT-1106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health