Provider Demographics
NPI:1417160169
Name:CROCKETT, MARY J (OTRL)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 GREEN LANE
Mailing Address - Street 2:
Mailing Address - City:SILVER BAY
Mailing Address - State:MN
Mailing Address - Zip Code:55614-1235
Mailing Address - Country:US
Mailing Address - Phone:218-226-0194
Mailing Address - Fax:
Practice Address - Street 1:1800 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880
Practice Address - Country:US
Practice Address - Phone:715-394-5591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4163026225X00000X
MN101276225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist