Provider Demographics
NPI:1447775317
Name:CROCKETT, KAITLIN CROCKETT (ATC, LMT)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:CROCKETT
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:ATC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5747 MEMORIAL GYM
Mailing Address - Street 2:
Mailing Address - City:ORONO
Mailing Address - State:ME
Mailing Address - Zip Code:04469-5747
Mailing Address - Country:US
Mailing Address - Phone:207-581-4288
Mailing Address - Fax:207-581-4474
Practice Address - Street 1:5747 MEMORIAL GYM
Practice Address - Street 2:
Practice Address - City:ORONO
Practice Address - State:ME
Practice Address - Zip Code:04469-5747
Practice Address - Country:US
Practice Address - Phone:207-581-4288
Practice Address - Fax:207-581-4474
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME225700000X
MEAT4832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist