Provider Demographics
NPI:1720277536
Name:PROCTOR, EILEEN W (PHD)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:W
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4513 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:95635-9635
Mailing Address - Country:US
Mailing Address - Phone:619-569-0938
Mailing Address - Fax:
Practice Address - Street 1:4513 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:CA
Practice Address - Zip Code:95635-9635
Practice Address - Country:US
Practice Address - Phone:619-569-0938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 12736103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical