Provider Demographics
NPI:1699573006
Name:PROCTOR, ALIDA (RBT)
Entity type:Individual
Prefix:
First Name:ALIDA
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3006 EASTPOINT PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4185
Mailing Address - Country:US
Mailing Address - Phone:502-795-0773
Mailing Address - Fax:
Practice Address - Street 1:5155 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46217-3764
Practice Address - Country:US
Practice Address - Phone:502-795-0773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-19-99076106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician