Provider Demographics
NPI:1073650982
Name:HUMPHREY, MARY ELIZABETH (MSP)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:ELIZABETH
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:MSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WILLOW FORKS DR
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-5971
Mailing Address - Country:US
Mailing Address - Phone:843-670-2593
Mailing Address - Fax:
Practice Address - Street 1:114 WILLOW FORKS DR
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-5971
Practice Address - Country:US
Practice Address - Phone:843-670-2593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3894235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist