Provider Demographics
NPI:1639576721
Name:PROCTOR, TAMIE
Entity Type:Individual
Prefix:
First Name:TAMIE
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SALTER RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-9702
Mailing Address - Country:US
Mailing Address - Phone:859-779-5052
Mailing Address - Fax:
Practice Address - Street 1:700 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1558
Practice Address - Country:US
Practice Address - Phone:859-986-0650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1397101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional