Healthcare Provider Details

I. General information

NPI: 1336188655
Provider Name (Legal Business Name): MELISSA SUE PROCTOR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8804 PATTERSON AVE
RICHMOND VA
23229-6361
US

IV. Provider business mailing address

815 PORTER ST APT 308
RICHMOND VA
23224-2272
US

V. Phone/Fax

Practice location:
  • Phone: 804-592-6311
  • Fax:
Mailing address:
  • Phone: 619-929-4921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number62650
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904015618
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4948
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: