Provider Demographics
NPI:1275070179
Name:HUMPHREY, HELEN
Entity Type:Individual
Prefix:
First Name:HELEN
Middle Name:
Last Name:HUMPHREY
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 1:713 S MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-5808
Mailing Address - Country:US
Mailing Address - Phone:336-722-7266
Mailing Address - Fax:336-201-0538
Practice Address - Street 1:104 CAMBRIDGE PLAZA DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3556
Practice Address - Country:US
Practice Address - Phone:336-722-7266
Practice Address - Fax:336-201-0538
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12771101YP2500X
NC12771101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional