Healthcare Provider Details

I. General information

NPI: 1811812050
Provider Name (Legal Business Name): MADELINE CROCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADELINE BROWN

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9434 W FAIRVIEW AVE
BOISE ID
83704-8101
US

IV. Provider business mailing address

9434 W FAIRVIEW AVE
BOISE ID
83704-8101
US

V. Phone/Fax

Practice location:
  • Phone: 208-495-6715
  • Fax: 208-684-7835
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number6681919
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: