Provider Demographics
NPI:1003851114
Name:HUMPHREYS, ANDREA PEARL (OTR/L)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:PEARL
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3213 N 8TH PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8221
Mailing Address - Country:US
Mailing Address - Phone:918-894-3700
Mailing Address - Fax:
Practice Address - Street 1:3213 N 8TH PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8221
Practice Address - Country:US
Practice Address - Phone:918-894-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1231174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200017780Medicaid