Provider Demographics
NPI:1407682446
Name:CROCKETT, ALYSSA (LMT)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-5705
Mailing Address - Country:US
Mailing Address - Phone:207-461-5824
Mailing Address - Fax:
Practice Address - Street 1:118 MAINE MALL RD
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2309
Practice Address - Country:US
Practice Address - Phone:207-772-1031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT6607171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor