MEDICARE: MS. LINDA H CROCKETT

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	104100000X	Social Worker	8689	LA

General Provider Information

NPI Number	:	1063746915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LINDA H CROCKETT

Provider Business Mailing Address
First Line	:	3734 LA HIGHWAY 1 S
Second Line	:
City	:	PORT ALLEN
State	:	LA
Zip	:	70767-5815
Country	:	US
Telephone Number	:	225-288-3739
Fax Number	:

Provider Business Practice Location Address
First Line	:	3734 LA HIGHWAY 1 S
Second Line	:
City	:	PORT ALLEN
State	:	LA
Zip	:	70767-5815
Country	:	US
Telephone Number	:	225-288-3739
Fax Number	:

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

Provider Enumeration Date	:	09/24/2009
Last Update Date	:	09/24/2009

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