Provider Demographics
NPI:1952324865
Name:PROCTOR, CYNTHIA
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:
Other - Last Name:PROCTOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CMHC
Mailing Address - Street 1:PO BOX 1287
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-1287
Mailing Address - Country:US
Mailing Address - Phone:801-524-8635
Mailing Address - Fax:
Practice Address - Street 1:423 W 800 S
Practice Address - Street 2:SUITE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-2213
Practice Address - Country:US
Practice Address - Phone:801-524-8635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6255159-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870303448Medicaid