Provider Demographics
NPI:1629557145
Name:PROCTOR, KAITLIN BAKER (PHD)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:BAKER
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:DENISE
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:245 E TRINITY PL UNIT 1425
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3494
Mailing Address - Country:US
Mailing Address - Phone:205-999-2298
Mailing Address - Fax:
Practice Address - Street 1:1920 BRIARCLIFF RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-4010
Practice Address - Country:US
Practice Address - Phone:404-785-9350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004209103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent