Provider Demographics
NPI:1922691484
Name:PROCTOR, NIYA RENEE
Entity Type:Individual
Prefix:
First Name:NIYA
Middle Name:RENEE
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 1:1411 GERMAN SCHOOL RD APT 203
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4176
Mailing Address - Country:US
Mailing Address - Phone:301-325-1050
Mailing Address - Fax:
Practice Address - Street 1:2009 CADILLAC TRL
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-1817
Practice Address - Country:US
Practice Address - Phone:804-745-7411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09060097021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical