Basic Information
| Provider Information | |||||||||
| NPI: | 1588037519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROCTOR | ||||||||
| FirstName: | KANDICE | ||||||||
| MiddleName: | APPLEBY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, RCSWI | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | APPLEBY | ||||||||
| OtherFirstName: | KANDICE | ||||||||
| OtherMiddleName: | BROOKE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW, RCSWI | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367183550 | ||||||||
| FaxNumber: | 3362771825 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 KIMEL PARK DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367183550 | ||||||||
| FaxNumber: | 3362771825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2015 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | ISW8524 | FL | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | C013542 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.