Provider Demographics
NPI:1932390978
Name:CROCKETT, DELESKA (MA)
Entity Type:Individual
Prefix:
First Name:DELESKA
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 1:4010 E PROVIDENCE CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-3129
Mailing Address - Country:US
Mailing Address - Phone:812-334-2405
Mailing Address - Fax:
Practice Address - Street 1:600 N JORDAN AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3190
Practice Address - Country:US
Practice Address - Phone:812-855-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health