Provider Demographics
NPI:1952815359
Name:CROCKFORD, CARRIE (LMFT)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:CROCKFORD
Suffix:
Gender:F
Credentials:LMFT
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 833
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309
Mailing Address - Country:US
Mailing Address - Phone:612-306-4328
Mailing Address - Fax:
Practice Address - Street 1:25526 189TH ST NW
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-4509
Practice Address - Country:US
Practice Address - Phone:612-306-4328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3233106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty