Basic Information
| Provider Information | |||||||||
| NPI: | 1447775317 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROCKETT | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | CROCKETT | ||||||||
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| Credential: | ATC, LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5747 MEMORIAL GYM | ||||||||
| Address2: | |||||||||
| City: | ORONO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044695747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075814288 | ||||||||
| FaxNumber: | 2075814474 | ||||||||
| Practice Location | |||||||||
| Address1: | 5747 MEMORIAL GYM | ||||||||
| Address2: | |||||||||
| City: | ORONO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044695747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075814288 | ||||||||
| FaxNumber: | 2075814474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | ME | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 2255A2300X | AT483 | ME | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.