Provider Demographics
NPI:1295195386
Name:HUMPHRIES, JC MIELKE (LGSW)
Entity Type:Individual
Prefix:
First Name:JC
Middle Name:MIELKE
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8723 REICHS FORD RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-6851
Mailing Address - Country:US
Mailing Address - Phone:410-736-2187
Mailing Address - Fax:
Practice Address - Street 1:7474 GREENWAY CENTER DRIVE
Practice Address - Street 2:SUITE 730
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770
Practice Address - Country:US
Practice Address - Phone:301-345-1022
Practice Address - Fax:301-560-5558
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10174104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker