Provider Demographics
NPI:1073727871
Name:CROCKETT, DANIEL A (COTA)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:A
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1841
Mailing Address - Country:US
Mailing Address - Phone:270-339-0355
Mailing Address - Fax:731-588-2732
Practice Address - Street 1:640 HANNINGS LN
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3308
Practice Address - Country:US
Practice Address - Phone:731-587-3193
Practice Address - Fax:731-588-2732
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001524224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant