Provider Demographics
NPI:1306008198
Name:PROCTER, THOMAS BRYAN (BA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BRYAN
Last Name:PROCTER
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4725 DEL CREST DR
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-3919
Mailing Address - Country:US
Mailing Address - Phone:405-831-8786
Mailing Address - Fax:
Practice Address - Street 1:4725 DEL CREST DR
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-3919
Practice Address - Country:US
Practice Address - Phone:405-831-8786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK04459101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health