Provider Demographics
NPI:1972657187
Name:CROCKER, CARRIE CAROLINE (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:CAROLINE
Last Name:CROCKER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 N DESLOGE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:DESLOGE
Mailing Address - State:MO
Mailing Address - Zip Code:63601-2937
Mailing Address - Country:US
Mailing Address - Phone:314-627-0313
Mailing Address - Fax:800-335-4761
Practice Address - Street 1:2020 BROADWAY ST
Practice Address - Street 2:SUITE D
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2973
Practice Address - Country:US
Practice Address - Phone:314-719-6263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030321961041C0700X
IL1490163861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497312108Medicaid