MEDICARE: ALEXANDRA CROCKETT PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY30646	CA
2	103TC0700X	Clinical Psychologist	4041	OR
3	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1467865170
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRA CROCKETT PSYD

Provider Business Mailing Address
First Line	:	1336 NW FLANDERS ST STE 100
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97209-2645
Country	:	US
Telephone Number	:	510-440-3622
Fax Number	:

Provider Business Practice Location Address
First Line	:	1336 NW FLANDERS ST STE 100
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97209-2645
Country	:	US
Telephone Number	:	510-440-3622
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2014
Last Update Date	:	06/02/2026

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