Provider Demographics
NPI:1104957042
Name:CROCKETT, ALISA D (LCSWC)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:D
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8767 LYNCH DR
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:MD
Mailing Address - Zip Code:21875-2471
Mailing Address - Country:US
Mailing Address - Phone:410-896-4185
Mailing Address - Fax:
Practice Address - Street 1:422 W. MARKET STREET
Practice Address - Street 2:MARKET SQUARE
Practice Address - City:SNOW HILL
Practice Address - State:MD
Practice Address - Zip Code:21863
Practice Address - Country:US
Practice Address - Phone:410-632-4510
Practice Address - Fax:410-632-4933
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD092341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS013Medicare ID - Type Unspecified