Provider Demographics
NPI:1922382621
Name:HUMPHREY, MARY (MA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 WELSH DR
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-1855
Mailing Address - Country:US
Mailing Address - Phone:315-487-8337
Mailing Address - Fax:
Practice Address - Street 1:111 WELSH DR
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-1855
Practice Address - Country:US
Practice Address - Phone:315-487-8337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005879-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist