Provider Demographics
NPI:1609111806
Name:PROCTOR, KATHRYN LISTER (PT, DPT)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:LISTER
Last Name:PROCTOR
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E BUTLER RD STE B
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-2154
Mailing Address - Country:US
Mailing Address - Phone:803-500-1339
Mailing Address - Fax:803-590-4400
Practice Address - Street 1:106 E BUTLER RD STE B
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2154
Practice Address - Country:US
Practice Address - Phone:803-500-1339
Practice Address - Fax:803-590-4400
Is Sole Proprietor?:No
Enumeration Date:2012-11-29
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL0014974225100000X, 208100000X
VA2305207747225100000X
DCPT871826225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC432136YT9Medicare PIN
DCG02816Medicare PIN