Provider Demographics
NPI:1205192549
Name:HUMPHREY, STEPHANIE SNYDER (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:SNYDER
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:381 CARRIAGE TRACE LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27295-5372
Mailing Address - Country:US
Mailing Address - Phone:336-853-7146
Mailing Address - Fax:
Practice Address - Street 1:2000 SALEMTOWNE DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3488
Practice Address - Country:US
Practice Address - Phone:336-776-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5484225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist