Provider Demographics
NPI:1881861177
Name:CROCKER, AMY (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CROCKER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 SAPLING CIR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-7779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3205 KITTY HAWK RD
Practice Address - Street 2:SUITE 4
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-8629
Practice Address - Country:US
Practice Address - Phone:910-343-5885
Practice Address - Fax:910-343-5886
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2763235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist