Provider Demographics
NPI:1124131750
Name:CROCKETT, LEANN DAWN (MSPT)
Entity type:Individual
Prefix:MRS
First Name:LEANN
Middle Name:DAWN
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92410 OVERSEAS HIGHWAY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:TAVERNIER
Mailing Address - State:FL
Mailing Address - Zip Code:33070-2636
Mailing Address - Country:US
Mailing Address - Phone:305-587-7770
Mailing Address - Fax:305-852-8300
Practice Address - Street 1:92410 OVERSEAS HIGHWAY
Practice Address - Street 2:SUITE 6
Practice Address - City:TAVERNIER
Practice Address - State:FL
Practice Address - Zip Code:33070-2636
Practice Address - Country:US
Practice Address - Phone:305-587-7770
Practice Address - Fax:305-852-8300
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21750225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001268400Medicaid
FL001268400Medicaid