Provider Demographics
NPI:1992574990
Name:CROCKETT, RANDALL CALEB (OT)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:CALEB
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 W WEDDING TRL
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-6467
Mailing Address - Country:US
Mailing Address - Phone:801-867-7492
Mailing Address - Fax:
Practice Address - Street 1:2260 W WEDDING TRL
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-6467
Practice Address - Country:US
Practice Address - Phone:801-867-7492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-008328225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist