MEDICARE: EILEEN W. PROCTOR PH.D.

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	103TC0700X	Clinical Psychologist	PSY 12736	CA

General Provider Information

NPI Number	:	1720277536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EILEEN W. PROCTOR PH.D.

Provider Business Mailing Address
First Line	:	4513 EDGEWATER DR
Second Line	:
City	:	GREENWOOD
State	:	CA
Zip	:	95635-9635
Country	:	US
Telephone Number	:	619-569-0938
Fax Number	:

Provider Business Practice Location Address
First Line	:	4513 EDGEWATER DR
Second Line	:
City	:	GREENWOOD
State	:	CA
Zip	:	95635-9635
Country	:	US
Telephone Number	:	619-569-0938
Fax Number	:

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

Provider Enumeration Date	:	10/17/2007
Last Update Date	:	07/21/2022

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