Provider Demographics
NPI:1255637203
Name:PROCTOR, MELVIN WALTER DAVID (PCC-S)
Entity type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:WALTER DAVID
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:PCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2495 W MARKET ST STE C
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-8450
Mailing Address - Country:US
Mailing Address - Phone:141-944-3120
Mailing Address - Fax:141-944-3152
Practice Address - Street 1:2495 W MARKET ST STE C
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8450
Practice Address - Country:US
Practice Address - Phone:141-944-3120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE-0002670101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health