Provider Demographics
NPI:1205220191
Name:EDWARDS CROCKETT, MARGAUX
Entity Type:Individual
Prefix:
First Name:MARGAUX
Middle Name:
Last Name:EDWARDS 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:PO BOX 653
Mailing Address - Street 2:
Mailing Address - City:DONNELLY
Mailing Address - State:ID
Mailing Address - Zip Code:83615-0653
Mailing Address - Country:US
Mailing Address - Phone:208-860-2488
Mailing Address - Fax:
Practice Address - Street 1:125 COMMERCE ST
Practice Address - Street 2:SUITE B
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-5192
Practice Address - Country:US
Practice Address - Phone:888-634-7817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5683101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional