Provider Demographics
NPI:1376848309
Name:CROCKETT, BRIAN P (LADC I)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:P
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:LADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-2777
Mailing Address - Country:US
Mailing Address - Phone:508-880-1598
Mailing Address - Fax:
Practice Address - Street 1:66 MAIN ST
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-2777
Practice Address - Country:US
Practice Address - Phone:508-880-1598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2363101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)