Provider Demographics
NPI:1629646609
Name:CROCKER, MARY CLARE (LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CLARE
Last Name:CROCKER
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 1:1911 W CHAFFEE PL
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-1542
Mailing Address - Country:US
Mailing Address - Phone:469-560-2330
Mailing Address - Fax:
Practice Address - Street 1:5277 MANHATTAN CIR STE 250
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-8212
Practice Address - Country:US
Practice Address - Phone:303-746-7844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82375101YP2500X
COLPC0017108101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty