Provider Demographics
NPI:1093362006
Name:CROCKETT, DEQUITA (GCDF, NCDF)
Entity Type:Individual
Prefix:
First Name:DEQUITA
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:GCDF, NCDF
Other - Prefix:
Other - First Name:DEQUITA
Other - Middle Name:
Other - Last Name:CROCKETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DLT TRUST INC
Mailing Address - Street 1:300 S RODNEY PARHAM RD STE 1-326
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4747
Mailing Address - Country:US
Mailing Address - Phone:870-623-5415
Mailing Address - Fax:
Practice Address - Street 1:300 S RODNEY PARHAM RD STE 1-326
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-4747
Practice Address - Country:US
Practice Address - Phone:870-623-5415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor