Provider Demographics
NPI:1477675064
Name:WANDA A. CROCKETT PLLC
Entity Type:Organization
Organization Name:WANDA A. CROCKETT PLLC
Other - Org Name:NEW DIRECTION PSYCHIATRIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:804-748-4774
Mailing Address - Street 1:9500 GADWELL TER
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23838-5215
Mailing Address - Country:US
Mailing Address - Phone:804-748-4774
Mailing Address - Fax:
Practice Address - Street 1:1480 OAK BRIDGE CT
Practice Address - Street 2:
Practice Address - City:POWHATAN
Practice Address - State:VA
Practice Address - Zip Code:23139-8054
Practice Address - Country:US
Practice Address - Phone:804-423-1389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty