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 1:301 LARKSPUR DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-6225
Mailing Address - Country:US
Mailing Address - Phone:276-639-5676
Mailing Address - Fax:
Practice Address - Street 1:1536 BRIDGEWATER LN STE 104
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4103
Practice Address - Country:US
Practice Address - Phone:423-534-7824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2024-08-14
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
TN4912OtherLPC-MHSP