Provider Demographics
NPI:1619939808
Name:CROCKER, LATOYA D (MPT)
Entity Type:Individual
Prefix:MS
First Name:LATOYA
Middle Name:D
Last Name:CROCKER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 PILOT HOUSE DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:12655 WARWICK BLVD
Practice Address - Street 2:STE B
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606
Practice Address - Country:US
Practice Address - Phone:757-599-5551
Practice Address - Fax:757-595-5238
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305203475225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA192965OtherBCBS PHY THERAPY
VA8953015Medicaid
VA7080444OtherAETNA
VAC05954Medicare PIN
VA8953015Medicaid