Provider Demographics
NPI:1497245419
Name:CROCKETT, IYAHNA
Entity Type:Individual
Prefix:
First Name:IYAHNA
Middle Name:
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 1:1321 MURFREESBORO PIKE STE 702
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37217-2679
Mailing Address - Country:US
Mailing Address - Phone:615-724-4722
Mailing Address - Fax:803-905-4431
Practice Address - Street 1:2460 INDIA HOOK RD STE AND105
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3530
Practice Address - Country:US
Practice Address - Phone:803-366-6250
Practice Address - Fax:803-366-6261
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17-44081106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician