Provider Demographics
NPI:1003803578
Name:CROCKETT, WANDA A (LPC)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:A
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 BREMO RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2438
Mailing Address - Country:US
Mailing Address - Phone:804-288-1881
Mailing Address - Fax:804-288-1881
Practice Address - Street 1:2006 BREMO RD
Practice Address - Street 2:SUITE 101
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2438
Practice Address - Country:US
Practice Address - Phone:804-288-1881
Practice Address - Fax:804-288-1881
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA07010000950101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005401895Medicaid