Provider Demographics
NPI:1861814162
Name:CROCKETT, MAYUKA (LAC)
Entity Type:Individual
Prefix:MRS
First Name:MAYUKA
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 W MCDERMOTT DR STE 248
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-3089
Mailing Address - Country:US
Mailing Address - Phone:972-379-8176
Mailing Address - Fax:
Practice Address - Street 1:1333 W MCDERMOTT DR STE 248
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-3089
Practice Address - Country:US
Practice Address - Phone:972-379-8176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01478171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist