Basic Information
Provider Information | |||||||||
NPI: | 1528228806 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PROCTOR | ||||||||
FirstName: | STEVEN | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 651 MEMORIAL DR | ||||||||
Address2: |   | ||||||||
City: | POCATELLO | ||||||||
State: | ID | ||||||||
PostalCode: | 832014071 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082392110 | ||||||||
FaxNumber: | 2082392136 | ||||||||
Practice Location | |||||||||
Address1: | 651 MEMORIAL DR | ||||||||
Address2: |   | ||||||||
City: | POCATELLO | ||||||||
State: | ID | ||||||||
PostalCode: | 832014071 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082392110 | ||||||||
FaxNumber: | 2082392136 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2008 | ||||||||
LastUpdateDate: | 06/11/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | LCSW-1186 | 01 | ID | IDAHO STATE LICENSE | OTHER |