Provider Demographics
NPI:1255738837
Name:CROCKETT, MALLORI (ATC)
Entity type:Individual
Prefix:
First Name:MALLORI
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 6TH AVE BOX 870308
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35487-1409
Mailing Address - Country:US
Mailing Address - Phone:205-348-3607
Mailing Address - Fax:205-348-4419
Practice Address - Street 1:801 6TH AVE
Practice Address - Street 2:BOX 870308
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35487-1409
Practice Address - Country:US
Practice Address - Phone:205-348-5832
Practice Address - Fax:205-348-9770
Is Sole Proprietor?:No
Enumeration Date:2014-11-26
Last Update Date:2019-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1537208100000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000003186OtherBOC #
AL1537OtherLICENSURE #