Provider Demographics
NPI:1710254073
Name:CROCCO, MICHAEL ANTHONY (MED, MA, LCMHC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:CROCCO
Suffix:
Gender:M
Credentials:MED, MA, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 TAMARACK RD
Mailing Address - Street 2:
Mailing Address - City:LEE
Mailing Address - State:NH
Mailing Address - Zip Code:03861-6317
Mailing Address - Country:US
Mailing Address - Phone:603-674-2438
Mailing Address - Fax:
Practice Address - Street 1:222 COURT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-4416
Practice Address - Country:US
Practice Address - Phone:603-674-2438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH525101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30423232Medicaid