Provider Demographics
NPI:1245875962
Name:PROCTOR, MYRON RUSSELL (CADC, LMSW)
Entity type:Individual
Prefix:MR
First Name:MYRON
Middle Name:RUSSELL
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:CADC, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 LAZY OAK TRL
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-5573
Mailing Address - Country:US
Mailing Address - Phone:423-785-7391
Mailing Address - Fax:
Practice Address - Street 1:201 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-2419
Practice Address - Country:US
Practice Address - Phone:678-590-5589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0527101YA0400X
GAMSW011227104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)