Basic Information
| Provider Information | |||||||||
| NPI: | 1235651183 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROCKETT | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | M.ED. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8153 KAITLIN LN | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373635910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237167127 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6110 SHALLOWFORD RD STE B | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374211894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234991031 | ||||||||
| FaxNumber: | 4232966384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2017 | ||||||||
| LastUpdateDate: | 07/12/2017 | ||||||||
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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 | 101YS0200X | 000702717 | TN | N | Behavioral Health & Social Service Providers | Counselor | School | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.