Provider Demographics
NPI:1487263190
Name:PROCTOR, NICOLE JOLENE (MSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:JOLENE
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 S EL CAMINO REAL STE 102
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-6209
Mailing Address - Country:US
Mailing Address - Phone:971-400-7042
Mailing Address - Fax:
Practice Address - Street 1:409 CAMINO DEL RIO S STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3505
Practice Address - Country:US
Practice Address - Phone:619-381-7748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-39660104100000X
CA1060551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker