Provider Demographics
NPI:1255521951
Name:CROCKETT, HEIDI (LCSW, LMT)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:LCSW, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33706-1912
Mailing Address - Country:US
Mailing Address - Phone:727-288-4117
Mailing Address - Fax:
Practice Address - Street 1:1432 DR MARTIN LUTHER KING JR ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-3302
Practice Address - Country:US
Practice Address - Phone:727-288-4117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-29
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA42442225700000X
FLSW125811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC2933OtherBLUE CROSS BLUE SHIELD PR