Provider Demographics
NPI:1730396987
Name:CROCKER, MICHAEL (LCSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:CROCKER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 W 57TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-3159
Mailing Address - Country:US
Mailing Address - Phone:212-977-5835
Mailing Address - Fax:
Practice Address - Street 1:333 W 57TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3159
Practice Address - Country:US
Practice Address - Phone:212-977-5835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0551891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNV6881Medicare ID - Type UnspecifiedCLINICAL SOCIAL WORKER