Provider Demographics
NPI:1164746947
Name:CROCETTO, JOHANNA SARAH (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:SARAH
Last Name:CROCETTO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 COVERED BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-1769
Mailing Address - Country:US
Mailing Address - Phone:860-324-8792
Mailing Address - Fax:
Practice Address - Street 1:519 MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:ROYERSFORD
Practice Address - State:PA
Practice Address - Zip Code:19468-2305
Practice Address - Country:US
Practice Address - Phone:860-324-8792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW125699104100000X
PACW0171821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1487745386Medicaid
PA461199781Medicaid