Provider Demographics
NPI:1366137689
Name:CROCKETT, KIAIRA (PTA)
Entity type:Individual
Prefix:MS
First Name:KIAIRA
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 SYMPHONY ST APT B
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-2374
Mailing Address - Country:US
Mailing Address - Phone:419-371-9705
Mailing Address - Fax:
Practice Address - Street 1:8630 WASHINGTON CHURCH RD
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-3795
Practice Address - Country:US
Practice Address - Phone:937-291-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011863225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant