Provider Demographics
NPI:1306500657
Name:CROCKETT, AINIGRIV (LCPC)
Entity type:Individual
Prefix:
First Name:AINIGRIV
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8894 STANFORD BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-5161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8894 STANFORD BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-4794
Practice Address - Country:US
Practice Address - Phone:240-839-1361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC12104101YM0800X
MDLGP10310101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health