Provider Demographics
NPI:1912963141
Name:CROCKETT, LAWRENCE O SR (AUD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:O
Last Name:CROCKETT
Suffix:SR
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 NACOOCHEE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-1823
Mailing Address - Country:US
Mailing Address - Phone:706-546-5689
Mailing Address - Fax:706-543-7675
Practice Address - Street 1:150 NACOOCHEE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-1823
Practice Address - Country:US
Practice Address - Phone:706-546-5689
Practice Address - Fax:706-543-7675
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD003507231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000848273BMedicaid
GA581585042OtherATHENS AREA HEALTH PLAN S
GA581585042OtherBCBSOF GA
GA584585042OtherUNITED HEALTH CARE
GA581585042OtherBCBSOF GA