Provider Demographics
NPI:1316049778
Name:CROCKETT & ASSOC. COMM. CLINICS
Entity type:Organization
Organization Name:CROCKETT & ASSOC. COMM. CLINICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:E
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:813-933-0455
Mailing Address - Street 1:2914 BUSCH LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-1859
Mailing Address - Country:US
Mailing Address - Phone:813-933-0455
Mailing Address - Fax:813-933-0457
Practice Address - Street 1:2914 BUSCH LAKE BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-1859
Practice Address - Country:US
Practice Address - Phone:813-933-0455
Practice Address - Fax:813-933-0457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA774235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty