Provider Demographics
NPI:1376178764
Name:HUMPHREY, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 LAKE ELLENOR DR STE 212
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-4632
Mailing Address - Country:US
Mailing Address - Phone:407-325-2235
Mailing Address - Fax:
Practice Address - Street 1:6100 LAKE ELLENOR DR STE 212
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4632
Practice Address - Country:US
Practice Address - Phone:407-325-2235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker