Myron Russell Proctor, CADC, LMSW

Primary specialty

Social WorkerTaxonomy code 104100000X

License

MSW011227 Issued in GA

Practice address

201 N Main St
La Fayette, GA 30728-2419

Phone

(678) 590-5589

NPI assigned

Nov 18, 2019

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1574035200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1692576000000",
    "number": "1245875962",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "121 LAZY OAK TRL",
            "city": "RINGGOLD",
            "state": "GA",
            "postal_code": "307365573",
            "telephone_number": "423-785-7391"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "201 N MAIN ST",
            "city": "LA FAYETTE",
            "state": "GA",
            "postal_code": "307282419",
            "telephone_number": "678-590-5589"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "6120 Alabama Hwy",
            "address_purpose": "LOCATION",
            "city": "Ringgold",
            "state": "GA",
            "postal_code": "307362804",
            "country_code": "US",
            "telephone_number": "706-935-6442",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PROCTOR",
        "first_name": "MYRON",
        "middle_name": "RUSSELL",
        "name_prefix": "Mr.",
        "credential": "CADC, LMSW",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-11-18",
        "last_updated": "2023-08-21",
        "certification_date": "2023-08-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "GA",
            "license": "0527",
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "GA",
            "license": "MSW011227",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Physical Therapy Plus, LLC
• Primary Health Care Center of Dade, Inc.
• Primary Health Care Center of Dade, Inc.
• Primary Health Care Center of Dade, Inc.
• Primary Health Care Center of Dade, Inc.
• Pruitthealth - Lafayette, LLC
• Pruitthealth - Shepherd Hills, LLC
• Angie Roe
• Bonnie Lynn Rose, RN
• Tabatha Russell

• Social Worker in La Fayette, GA
• Providers in La Fayette, GA by specialty
• Social Worker in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 21, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.