Provider Demographics
NPI:1295426773
Name:PROCTOR, KATIE JEAN (LMSW)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:JEAN
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1537 HIDDEN CREEK CIRCLE DR NE APT A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5485
Mailing Address - Country:US
Mailing Address - Phone:734-564-1259
Mailing Address - Fax:
Practice Address - Street 1:1537 HIDDEN CREEK CIRCLE DR NE APT A
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5485
Practice Address - Country:US
Practice Address - Phone:734-564-1259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801112220101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health