Provider Demographics
NPI:1205837713
Name:CROCKETT, CAROL V (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:V
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087
Mailing Address - Country:US
Mailing Address - Phone:615-444-9400
Mailing Address - Fax:615-444-9406
Practice Address - Street 1:521 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087
Practice Address - Country:US
Practice Address - Phone:615-444-9400
Practice Address - Fax:615-444-9406
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN70225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN70OtherTN LICENSE