Provider Demographics
NPI:1760827935
Name:CROCKETT, TAMARA ELIZABETH (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:ELIZABETH
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 WISTERIA LN
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-3671
Mailing Address - Country:US
Mailing Address - Phone:336-362-6346
Mailing Address - Fax:
Practice Address - Street 1:318 WISTERIA LN
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-3671
Practice Address - Country:US
Practice Address - Phone:336-362-6346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7786225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist