Provider Demographics
NPI:1336188655
Name:PROCTOR, MELISSA SUE (MSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:619-269-0674
Practice Address - Street 1:327 NORTH MAIN PARK SHOPPING CENTER
Practice Address - Street 2:
Practice Address - City:OWENTON
Practice Address - State:KY
Practice Address - Zip Code:40359
Practice Address - Country:US
Practice Address - Phone:859-484-3464
Practice Address - Fax:859-484-0894
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA626501041C0700X
KY4948104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS184607OtherMEDICARE GROUP NUMBER
KY610661458OtherFEDERAL TAX ID NUMBER