Provider Demographics
NPI:1851856181
Name:PROCTOR, CARLOS (MAMAFT)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:MAMAFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 CONCORD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2814
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2324 CONCORD LAKE RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2814
Practice Address - Country:US
Practice Address - Phone:704-918-1343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14801101YP2500X
103TC1900X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling