Provider Demographics
NPI:1225173354
Name:CROCKER, ROY
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:
Last Name:CROCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 LAWRENCE 1189
Mailing Address - Street 2:
Mailing Address - City:ASH GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65604
Mailing Address - Country:US
Mailing Address - Phone:417-343-8556
Mailing Address - Fax:417-832-0059
Practice Address - Street 1:393 LAWRENCE 1189
Practice Address - Street 2:
Practice Address - City:ASH GROVE
Practice Address - State:MO
Practice Address - Zip Code:65604
Practice Address - Country:US
Practice Address - Phone:417-343-8556
Practice Address - Fax:417-832-0059
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003032197101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health