Provider Demographics
NPI:1396875068
Name:CROCKETT, CYNTHIA JEANINE (PHD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:JEANINE
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 COLUMBIA ST
Mailing Address - Street 2:SUITE 32
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6346
Mailing Address - Country:US
Mailing Address - Phone:207-942-1483
Mailing Address - Fax:
Practice Address - Street 1:43 COLUMBIA ST
Practice Address - Street 2:SUITE 32
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6346
Practice Address - Country:US
Practice Address - Phone:207-942-1483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS732103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist