Provider Demographics
NPI:1093692972
Name:CROCKETT, TARA (ACSW, PPSC)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:ACSW, PPSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5966
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-0966
Mailing Address - Country:US
Mailing Address - Phone:530-575-6679
Mailing Address - Fax:
Practice Address - Street 1:9510 ELK GROVE FLORIN RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1801
Practice Address - Country:US
Practice Address - Phone:916-892-2533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1194821041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool