Provider Demographics
NPI:1598928228
Name:CROCKFORD, GINA M (COTA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:CROCKFORD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SOUTH HILTON STREET
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705
Mailing Address - Country:US
Mailing Address - Phone:208-345-4464
Mailing Address - Fax:
Practice Address - Street 1:1001 S HILTON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1925
Practice Address - Country:US
Practice Address - Phone:208-345-4464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID006224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant