Basic Information
| Provider Information | |||||||||
| NPI: | 1003803578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROCKETT | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | A. | ||||||||
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| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2006 BREMO RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232262438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042881881 | ||||||||
| FaxNumber: | 8042881881 | ||||||||
| Practice Location | |||||||||
| Address1: | 2006 BREMO RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232262438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042881881 | ||||||||
| FaxNumber: | 8042881881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 11/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 07010000950 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 005401895 | 05 | VA | MEDICAID |