Provider Demographics
NPI:1871737478
Name:CROCKETT, ANTOINESE MICHELLE
Entity type:Individual
Prefix:MRS
First Name:ANTOINESE
Middle Name:MICHELLE
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7907 OSTROW ST STE F
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3635
Mailing Address - Country:US
Mailing Address - Phone:858-300-8282
Mailing Address - Fax:
Practice Address - Street 1:7907 OSTROW ST STE F
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3635
Practice Address - Country:US
Practice Address - Phone:858-300-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health