Healthcare Provider Details

I. General information

NPI: 1710818265
Provider Name (Legal Business Name): TOM CROCKETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 DIVISION ST
IOLA WI
54945-9629
US

IV. Provider business mailing address

151409 LILY LN
RIB MOUNTAIN WI
54401-5427
US

V. Phone/Fax

Practice location:
  • Phone: 715-445-2411
  • Fax:
Mailing address:
  • Phone: 888-801-2666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number661651
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: