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General NPI Number Information
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NPI Number | 1245875962
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Entity Type | Individual
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Provider Name | MYRON RUSSELL PROCTOR CADC, LMSW
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Gender | Male
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Dates
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Enumeration Date | 11/18/2019
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Last Update Date | 08/21/2023
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Provider Practice Location Address
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Address Line | 201 N MAIN ST
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City | LA FAYETTE
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State | GA
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Zip | 30728-2419
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Country | US
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Telephone | 678-590-5589
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Fax |
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Provider Business Mailing Address
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Address Line | 121 LAZY OAK TRL
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City | RINGGOLD
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State | GA
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Zip | 30736-5573
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Country | US
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Telephone | 423-785-7391
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 0527
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | MSW011227
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License Number State | GA
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