Provider Demographics
NPI:1073279345
Name:CROCKER, GEOFFREY ALLEN (MED, LGPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:GEOFFREY
Middle Name:ALLEN
Last Name:CROCKER
Suffix:
Gender:M
Credentials:MED, LGPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 RAVENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-7695
Mailing Address - Country:US
Mailing Address - Phone:443-617-8862
Mailing Address - Fax:
Practice Address - Street 1:8229 CLOVERLEAF DR STE 425
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1594
Practice Address - Country:US
Practice Address - Phone:443-617-8862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP12143101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional