Provider Demographics
NPI:1821588187
Name:CROCKETT, NIDYA (LCSW)
Entity Type:Individual
Prefix:
First Name:NIDYA
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:LCSW
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 70847
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92513-0847
Mailing Address - Country:US
Mailing Address - Phone:310-908-9797
Mailing Address - Fax:
Practice Address - Street 1:8798 PHILBIN AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-1732
Practice Address - Country:US
Practice Address - Phone:310-908-9797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-12
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1026871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty