=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407682446
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSSA CROCKETT LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2024
-----------------------------------------------------
Last Update Date | 09/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 118 MAINE MALL RD
-----------------------------------------------------
City | SOUTH PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04106-2309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-772-1031
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 58 ACADEMY ST
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04210-5705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-461-5824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number | MT6607
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------