Provider Demographics
NPI:1265022297
Name:HUMPHREYS, MADISON SKYE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:SKYE
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8321 NW 109TH TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-3012
Mailing Address - Country:US
Mailing Address - Phone:405-802-0732
Mailing Address - Fax:
Practice Address - Street 1:6905 NW 122ND ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-3903
Practice Address - Country:US
Practice Address - Phone:405-603-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-23
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKCF-186235Z00000X
OKSP-5556235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist