Provider Demographics
NPI:1396927927
Name:CROCKETT, KASELAH (MA)
Entity type:Individual
Prefix:MS
First Name:KASELAH
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-3639
Mailing Address - Country:US
Mailing Address - Phone:510-434-9232
Mailing Address - Fax:510-434-9292
Practice Address - Street 1:111 MYRTLE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-2525
Practice Address - Country:US
Practice Address - Phone:510-839-3800
Practice Address - Fax:510-839-3888
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health