Provider Demographics
NPI:1396868329
Name:PROCTOR, JOANN B (LC2383)
Entity Type:Individual
Prefix:MRS
First Name:JOANN
Middle Name:B
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:LC2383
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15406 JENNINGS LANE
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20744
Mailing Address - Country:US
Mailing Address - Phone:301-218-7333
Mailing Address - Fax:
Practice Address - Street 1:3060 MITCHEVILLE ROAD
Practice Address - Street 2:SUITE 212
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716
Practice Address - Country:US
Practice Address - Phone:301-218-5492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2383101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional