Provider Demographics
NPI:1336188655
Name:PROCTOR, MELISSA SUE (LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
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 1:815 PORTER ST APT 308
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-2272
Mailing Address - Country:US
Mailing Address - Phone:619-929-4921
Mailing Address - Fax:
Practice Address - Street 1:8804 PATTERSON AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-6361
Practice Address - Country:US
Practice Address - Phone:804-592-6311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA626501041C0700X
VA09040156181041C0700X
KY4948104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA62650OtherBOARD OF BEHAVIORAL SCIENCES
KY1336188655Medicaid
VA0904015618OtherCOMMONWEALTH OF VIRGINIA