Provider Demographics
NPI:1568674117
Name:CROCKETT, JOSHUA ELI (MHAI)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:ELI
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:MHAI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8615 FAIR OAKS BLVD
Mailing Address - Street 2:APT 1
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-2523
Mailing Address - Country:US
Mailing Address - Phone:916-944-8589
Mailing Address - Fax:
Practice Address - Street 1:2830 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2301
Practice Address - Country:US
Practice Address - Phone:916-736-6727
Practice Address - Fax:916-736-2470
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator