Provider Demographics
NPI:1386118800
Name:CROCKETT, TITUS LERAUN
Entity type:Individual
Prefix:
First Name:TITUS
Middle Name:LERAUN
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:MARKED TREE
Mailing Address - State:AR
Mailing Address - Zip Code:72365-2001
Mailing Address - Country:US
Mailing Address - Phone:870-882-2359
Mailing Address - Fax:
Practice Address - Street 1:101 RAYMOND ST
Practice Address - Street 2:
Practice Address - City:MARKED TREE
Practice Address - State:AR
Practice Address - Zip Code:72365-2001
Practice Address - Country:US
Practice Address - Phone:870-882-2359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator