Provider Demographics
NPI:1700626553
Name:CROCKER, THOMAS EARL
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:EARL
Last Name:CROCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 W SWAIN RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-4055
Mailing Address - Country:US
Mailing Address - Phone:209-953-8868
Mailing Address - Fax:
Practice Address - Street 1:2010 W SWAIN RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-4055
Practice Address - Country:US
Practice Address - Phone:209-953-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19019061103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool