Provider Demographics
NPI:1962852582
Name:CROCKETT, MAGGI (PTA)
Entity Type:Individual
Prefix:
First Name:MAGGI
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:12052 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:ALSIP
Practice Address - State:IL
Practice Address - Zip Code:60803-2313
Practice Address - Country:US
Practice Address - Phone:708-489-9940
Practice Address - Fax:708-489-9961
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.007483225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant