Provider Demographics
NPI:1073735734
Name:CROCKETT, MELISSA CROCKETT
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CROCKETT
Last Name:CROCKETT
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 1:9 YARMOUTH PL
Mailing Address - Street 2:APT #3
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5865
Mailing Address - Country:US
Mailing Address - Phone:617-869-4193
Mailing Address - Fax:
Practice Address - Street 1:9 YARMOUTH PL
Practice Address - Street 2:APT #3
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5865
Practice Address - Country:US
Practice Address - Phone:617-869-4193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7994225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant