Provider Demographics
NPI:1235653981
Name:PROCTOR, KAITLYN ELIZABETH
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ELIZABETH
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10304 SPOTSYLVANIA AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-8605
Mailing Address - Country:US
Mailing Address - Phone:919-890-5852
Mailing Address - Fax:
Practice Address - Street 1:8374 SIX FORKS RD STE 101
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5096
Practice Address - Country:US
Practice Address - Phone:919-890-5852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NC1-18-29948103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician