Provider Demographics
NPI:1861828410
Name:CROCILLA, ANTOINETTE (PSYD LP)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:CROCILLA
Suffix:
Gender:F
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2619
Practice Address - Country:US
Practice Address - Phone:734-682-5544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-15
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016439103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1982147302Medicaid