Provider Demographics
NPI:1114431863
Name:CROCKETT, CHANTEL (MA)
Entity Type:Individual
Prefix:
First Name:CHANTEL
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-4441
Mailing Address - Country:US
Mailing Address - Phone:225-465-3080
Mailing Address - Fax:225-465-3706
Practice Address - Street 1:530 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-4441
Practice Address - Country:US
Practice Address - Phone:225-465-3080
Practice Address - Fax:225-465-3706
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-16
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACIT5072101YA0400X
LA15883104100000X
251B00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No251B00000XAgenciesCase Management