Provider Demographics
NPI:1093242521
Name:PROCTOR, ANDRE
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 N TORREY PINES DR APT 2096
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-6528
Mailing Address - Country:US
Mailing Address - Phone:702-480-7416
Mailing Address - Fax:
Practice Address - Street 1:3081 S VALLEY VIEW BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-7890
Practice Address - Country:US
Practice Address - Phone:702-910-3230
Practice Address - Fax:702-910-3230
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker