Provider Demographics
NPI:1356547061
Name:CROCKER, NINA (LSW)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:CROCKER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 526
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-2739
Mailing Address - Country:US
Mailing Address - Phone:207-701-4477
Mailing Address - Fax:207-701-4486
Practice Address - Street 1:12 UNION ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2739
Practice Address - Country:US
Practice Address - Phone:207-701-4477
Practice Address - Fax:207-701-4486
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELSX8359101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health