Provider Demographics
NPI:1447254719
Name:CROCKETT, MADELEINE (PHD)
Entity type:Individual
Prefix:DR
First Name:MADELEINE
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 PROVIDENCE RD
Mailing Address - Street 2:STE 102
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-2273
Mailing Address - Country:US
Mailing Address - Phone:919-401-3680
Mailing Address - Fax:
Practice Address - Street 1:120 PROVIDENCE RD
Practice Address - Street 2:STE 102
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-2273
Practice Address - Country:US
Practice Address - Phone:919-401-3680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-02
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2129103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC03986OtherBLUE CROSS BLUE SHIELD
NC6000386Medicaid
NC2821418Medicare ID - Type Unspecified