Healthcare Provider Details

I. General information

NPI: 1073041497
Provider Name (Legal Business Name): SHELLEY L PROCTER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2017
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S ORANGE GROVE BLVD # CA
PASADENA CA
91105-1705
US

IV. Provider business mailing address

PO BOX 6355
DILLON CO
80435-6340
US

V. Phone/Fax

Practice location:
  • Phone: 562-263-6041
  • Fax:
Mailing address:
  • Phone: 760-803-7518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number140628
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: