Provider Demographics
NPI: | 1508055302 |
---|---|
Name: | PROCTOR, BARBARA ANN (MA, QMHP, LPC) |
Entity Type: | Individual |
Prefix: | |
First Name: | BARBARA |
Middle Name: | ANN |
Last Name: | PROCTOR |
Suffix: | |
Gender: | F |
Credentials: | MA, QMHP, LPC |
Other - Prefix: | |
Other - First Name: | BARBARA |
Other - Middle Name: | ANN |
Other - Last Name: | NUMEROWSKI |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 777 |
Mailing Address - Street 2: | |
Mailing Address - City: | RICHLAND |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 65556-0777 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 573-708-7600 |
Mailing Address - Fax: | 573-723-1474 |
Practice Address - Street 1: | 112 MCCLURG AVE |
Practice Address - Street 2: | |
Practice Address - City: | RICHLAND |
Practice Address - State: | MO |
Practice Address - Zip Code: | 65556 |
Practice Address - Country: | US |
Practice Address - Phone: | 573-765-5141 |
Practice Address - Fax: | 573-765-3824 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-10-17 |
Last Update Date: | 2023-05-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
101Y00000X | ||
IL | 180007422 | 101YP2500X |
MO | 2020040389 | 101YP2500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional |
No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MO | 1508055302 | Medicaid |