Provider Demographics
NPI:1093801979
Name:LEVINE-PROCTOR, BETSY K (PHD)
Entity type:Individual
Prefix:
First Name:BETSY
Middle Name:K
Last Name:LEVINE-PROCTOR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:K
Other - Last Name:LEVINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1 LINCOLN PARK UNIT 105
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2565
Mailing Address - Country:US
Mailing Address - Phone:415-497-6634
Mailing Address - Fax:
Practice Address - Street 1:1330 LINCOLN AVE STE 306
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2143
Practice Address - Country:US
Practice Address - Phone:415-497-6634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7136103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA215876Medicare PIN