Provider Demographics
NPI:1386927010
Name:PROCTOR, BRENT (PT)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 E LAFAYETTE PL
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-1331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 LILLY RD NE
Practice Address - Street 2:103
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5184
Practice Address - Country:US
Practice Address - Phone:360-459-0260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00002404225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist