MEDICARE: MELISSA SUE PROCTOR LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	62650	CA
2	1041C0700X	Clinical Social Worker	0904015618	VA
3	104100000X	Social Worker	4948	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	62650	OTHER	CA	BOARD OF BEHAVIORAL SCIENCES
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0904015618	OTHER	VA	COMMONWEALTH OF VIRGINIA

General Provider Information

NPI Number	:	1336188655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA SUE PROCTOR LCSW

Provider Business Mailing Address
First Line	:	815 PORTER ST APT 308
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23224-2272
Country	:	US
Telephone Number	:	619-929-4921
Fax Number	:

Provider Business Practice Location Address
First Line	:	8804 PATTERSON AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23229-6361
Country	:	US
Telephone Number	:	804-592-6311
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	06/26/2024

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