Provider Demographics
NPI:1235651183
Name:CROCKETT, SARA ELIZABETH (MED)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:ELIZABETH
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8153 KAITLIN LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-5910
Mailing Address - Country:US
Mailing Address - Phone:423-716-7127
Mailing Address - Fax:
Practice Address - Street 1:6110 SHALLOWFORD RD STE B
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1894
Practice Address - Country:US
Practice Address - Phone:423-499-1031
Practice Address - Fax:423-296-6384
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000702717101YS0200X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool