Provider Demographics
NPI:1801983861
Name:PROCTOR, LINDA (LCSW)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5703
Mailing Address - Country:US
Mailing Address - Phone:619-421-8212
Mailing Address - Fax:619-476-7566
Practice Address - Street 1:625 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5703
Practice Address - Country:US
Practice Address - Phone:619-421-8212
Practice Address - Fax:619-476-7566
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS99121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA228454OtherMHN PRACTICIONER ID
CACSW099120Medicaid
CAZZZ94881ZOtherBLUE SHIELD PROVIDER #
CASW9912Medicare UPIN