Basic Information
| Provider Information | |||||||||
| NPI: | 1952762668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROCKETT | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 DIVISION ST APT E38 | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700018805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049052714 | ||||||||
| FaxNumber: | 5044557626 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 TULANE AVE | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701122250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5047023000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2016 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.