Provider Demographics
NPI:1790189603
Name:PROCTOR, TERRELL (LPC)
Entity Type:Individual
Prefix:MR
First Name:TERRELL
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07014
Mailing Address - Country:US
Mailing Address - Phone:862-227-3975
Mailing Address - Fax:
Practice Address - Street 1:291 RIVER ROAD
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07014
Practice Address - Country:US
Practice Address - Phone:862-227-3975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00480500101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ47-1773345OtherEIN