Provider Demographics
NPI:1346358850
Name:CROCKETT, PETER DAVID (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:DAVID
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S WHITING ST
Mailing Address - Street 2:STE 605
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-7121
Mailing Address - Country:US
Mailing Address - Phone:703-751-2221
Mailing Address - Fax:703-212-7498
Practice Address - Street 1:205 S WHITING ST
Practice Address - Street 2:STE 605
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-7121
Practice Address - Country:US
Practice Address - Phone:703-751-2221
Practice Address - Fax:703-212-7498
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040003771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8922152Medicaid
VA8922152Medicaid