Provider Demographics
NPI:1033466693
Name:THOMAS-PROCTOR, PENNY (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:
Last Name:THOMAS-PROCTOR
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MRS
Other - First Name:PENELOPE
Other - Middle Name:
Other - Last Name:THOMAS-PROCTOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:2995 WOODSIDE RD
Mailing Address - Street 2:SUITE 400-172
Mailing Address - City:WOODSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2446
Mailing Address - Country:US
Mailing Address - Phone:650-363-0249
Mailing Address - Fax:
Practice Address - Street 1:165 ARCH ST
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-1303
Practice Address - Country:US
Practice Address - Phone:650-363-0249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 36602106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist