Healthcare Provider Details

I. General information

NPI: 1780074807
Provider Name (Legal Business Name): MICHAEL CROCKETT PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 SE 182ND AVE
GRESHAM OR
97030-5058
US

IV. Provider business mailing address

2315 NE FRANCIS CT
GRESHAM OR
97030-3155
US

V. Phone/Fax

Practice location:
  • Phone: 503-893-2249
  • Fax:
Mailing address:
  • Phone: 302-270-8286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: