Provider Demographics
NPI:1629234620
Name:CROCKETT, DAVID HUBERT LARUE (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:HUBERT LARUE
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1587
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85902-1587
Mailing Address - Country:US
Mailing Address - Phone:928-537-5696
Mailing Address - Fax:
Practice Address - Street 1:2201 N. 22ND AVE.
Practice Address - Street 2:SUITE NUMBER A
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-1587
Practice Address - Country:US
Practice Address - Phone:928-537-5696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-12500101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health