Provider Demographics
NPI:1184311201
Name:PROCTOR, REVA R (DODD CERTIFACTION)
Entity type:Individual
Prefix:
First Name:REVA
Middle Name:R
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:DODD CERTIFACTION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1877 ALLANDALE AVE
Mailing Address - Street 2:
Mailing Address - City:EAST CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112-2035
Mailing Address - Country:US
Mailing Address - Phone:216-352-8080
Mailing Address - Fax:
Practice Address - Street 1:1877 ALLANDALE AVE
Practice Address - Street 2:
Practice Address - City:EAST CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-2035
Practice Address - Country:US
Practice Address - Phone:216-352-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities