Provider Demographics
NPI:1952975005
Name:CROCKETT, MATTIE N (LPC, MHSP)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:N
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:LPC, MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 W MCKNIGHT DR
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-2450
Mailing Address - Country:US
Mailing Address - Phone:615-896-9160
Mailing Address - Fax:615-890-4555
Practice Address - Street 1:319 W MCKNIGHT DR
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-2450
Practice Address - Country:US
Practice Address - Phone:615-896-9160
Practice Address - Fax:615-890-4555
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4912101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4912OtherTEMP LIC