Provider Demographics
NPI:1124434972
Name:PROCTOR, LAURA J (PHD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:PHD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4370 LA JOLLA VILLAGE DR STE 400
Mailing Address - Street 2:MINDFUL PSYCHOTHERAPY, INC.
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-1251
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4370 LA JOLLA VILLAGE DR STE 400
Practice Address - Street 2:MINDFUL PSYCHOTHERAPY, INC.
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1251
Practice Address - Country:US
Practice Address - Phone:858-353-3345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29141103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical