Provider Demographics
NPI:1710714415
Name:PROCTOR, ALIAH MOET
Entity type:Individual
Prefix:
First Name:ALIAH
Middle Name:MOET
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3378 METROPOLITAN CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:INDIAN HEAD
Mailing Address - State:MD
Mailing Address - Zip Code:20640-3215
Mailing Address - Country:US
Mailing Address - Phone:240-721-0700
Mailing Address - Fax:
Practice Address - Street 1:9030 RED BRANCH RD STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2003
Practice Address - Country:US
Practice Address - Phone:443-863-6993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10272043536106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician