Provider Demographics
NPI:1912025586
Name:CROCKETT, CARL (MA)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:882 OAKMAN BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-4019
Mailing Address - Country:US
Mailing Address - Phone:313-961-7990
Mailing Address - Fax:313-883-6261
Practice Address - Street 1:882 OAKMAN BLVD STE D
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-4019
Practice Address - Country:US
Practice Address - Phone:313-961-7990
Practice Address - Fax:313-883-6261
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)