Provider Demographics
NPI:1366649808
Name:CROCKER, TAMMY L (MS CCC SLP)
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:L
Last Name:CROCKER
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 ANITA DR
Mailing Address - Street 2:
Mailing Address - City:HUBERT
Mailing Address - State:NC
Mailing Address - Zip Code:28539-4001
Mailing Address - Country:US
Mailing Address - Phone:910-388-2379
Mailing Address - Fax:
Practice Address - Street 1:139 ANITA DR
Practice Address - Street 2:
Practice Address - City:HUBERT
Practice Address - State:NC
Practice Address - Zip Code:28539-4001
Practice Address - Country:US
Practice Address - Phone:910-388-2379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4721235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412476Medicaid