Provider Demographics
NPI:1730833161
Name:CROCKETT, STEPHEN M (PTA)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 WESTMORELAND RD APT 205
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-4649
Mailing Address - Country:US
Mailing Address - Phone:814-403-6700
Mailing Address - Fax:
Practice Address - Street 1:8540 SCARBOROUGH DR STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7513
Practice Address - Country:US
Practice Address - Phone:303-322-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0015133225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant