Provider Demographics
NPI:1346552502
Name:PROCTOR, KRISTINE LOUISE (LMSW)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:LOUISE
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 NILES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9601
Mailing Address - Country:US
Mailing Address - Phone:269-405-0635
Mailing Address - Fax:269-408-0084
Practice Address - Street 1:3408 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9601
Practice Address - Country:US
Practice Address - Phone:269-405-0635
Practice Address - Fax:269-408-0084
Is Sole Proprietor?:No
Enumeration Date:2010-07-05
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010697831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical