Provider Demographics
NPI:1790381085
Name:CROCKER, SHAQUISHA
Entity Type:Individual
Prefix:
First Name:SHAQUISHA
Middle Name:
Last Name:CROCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 N MORRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-1551
Mailing Address - Country:US
Mailing Address - Phone:985-419-2430
Mailing Address - Fax:985-419-2431
Practice Address - Street 1:1814 N MORRISON BLVD
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-1551
Practice Address - Country:US
Practice Address - Phone:985-419-2430
Practice Address - Fax:985-419-2431
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1418882013Medicaid