Provider Demographics
NPI:1417233164
Name:PROCTOR, MARY BETH (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 E GRAND AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3313
Mailing Address - Country:US
Mailing Address - Phone:760-489-6083
Mailing Address - Fax:760-489-1193
Practice Address - Street 1:355 E GRAND AVE STE 4
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3313
Practice Address - Country:US
Practice Address - Phone:760-489-6083
Practice Address - Fax:760-489-1193
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT7700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist