Provider Demographics
NPI:1497326052
Name:CROCKETT, NICOLE CHRISTINE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:CHRISTINE
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:CHRISTINE
Other - Last Name:BRIX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 SE CROSS ST
Mailing Address - Street 2:
Mailing Address - City:MT STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:62353-1561
Mailing Address - Country:US
Mailing Address - Phone:217-773-3325
Mailing Address - Fax:217-773-2425
Practice Address - Street 1:120 N WILLIAMS INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1300
Practice Address - Country:US
Practice Address - Phone:217-285-4436
Practice Address - Fax:217-285-2804
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1501045931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical