Provider Demographics
NPI:1477015535
Name:CROCKETT, AMIRA GABRIELLE
Entity Type:Individual
Prefix:
First Name:AMIRA
Middle Name:GABRIELLE
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1464 S GREENMOUNT DR APT 309
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-2328
Mailing Address - Country:US
Mailing Address - Phone:301-266-2386
Mailing Address - Fax:
Practice Address - Street 1:7600 ARLINGTON RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-6200
Practice Address - Country:US
Practice Address - Phone:240-204-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD08200Medicaid