Provider Demographics
NPI:1629730650
Name:PROCTOR, DOMINQUE
Entity Type:Individual
Prefix:
First Name:DOMINQUE
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 STEUBENVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-2301
Mailing Address - Country:US
Mailing Address - Phone:855-692-7247
Mailing Address - Fax:855-692-7247
Practice Address - Street 1:841 STEUBENVILLE AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-2301
Practice Address - Country:US
Practice Address - Phone:855-692-7247
Practice Address - Fax:855-692-7247
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2105927104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker