Provider Demographics
NPI:1316191588
Name:PROCTOR, JOHN KENNETH (MSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:KENNETH
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3437 W 82ND PL
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90305-1602
Mailing Address - Country:US
Mailing Address - Phone:323-971-0877
Mailing Address - Fax:323-759-2697
Practice Address - Street 1:6519 8TH AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-4313
Practice Address - Country:US
Practice Address - Phone:323-750-5167
Practice Address - Fax:323-759-2697
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16760101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional