Provider Demographics
NPI:1730645052
Name:CROCKETT, JUDY L (MA, LLPC)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:L
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:MA, LLPC
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 75
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MI
Mailing Address - Zip Code:48880-0075
Mailing Address - Country:US
Mailing Address - Phone:989-502-2735
Mailing Address - Fax:
Practice Address - Street 1:115 CHESTNUT ST APT B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MI
Practice Address - Zip Code:48880-1308
Practice Address - Country:US
Practice Address - Phone:989-502-2735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016698101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401016698OtherSTATE OFMICHIGAN