Provider Demographics
NPI:1982734414
Name:CROCKETT, KATHLEEN (RPT)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:FITHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:BOX 349
Mailing Address - Street 2:400 S MAIN
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095
Mailing Address - Country:US
Mailing Address - Phone:618-251-2175
Mailing Address - Fax:618-251-6294
Practice Address - Street 1:400 S MAIN
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095
Practice Address - Country:US
Practice Address - Phone:618-251-2175
Practice Address - Fax:618-251-6294
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist