Provider Demographics
NPI:1609253814
Name:CROCKETT, MARIKA (PT)
Entity Type:Individual
Prefix:
First Name:MARIKA
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6572 CHICORY CT
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-1629
Mailing Address - Country:US
Mailing Address - Phone:512-657-5104
Mailing Address - Fax:
Practice Address - Street 1:4347 W NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75220-3864
Practice Address - Country:US
Practice Address - Phone:214-654-0947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12031972251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic