Provider Demographics
NPI:1346426582
Name:CROCKETT, RONALD DEAN
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:DEAN
Last Name:CROCKETT
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 1:115 GRACE MANOR DR
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-2559
Mailing Address - Country:US
Mailing Address - Phone:410-939-1655
Mailing Address - Fax:
Practice Address - Street 1:8800 WALTHER BLVD
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234-9001
Practice Address - Country:US
Practice Address - Phone:410-882-3262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3415225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist