Provider Demographics
NPI:1407400179
Name:HUMPHREY, EMILY RUTH (LOTR)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:RUTH
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:RUTH
Other - Last Name:HUMPHREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LOTR
Mailing Address - Street 1:125 LAKE POWELL DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71292-2107
Mailing Address - Country:US
Mailing Address - Phone:318-381-9356
Mailing Address - Fax:
Practice Address - Street 1:125 LAKE POWELL DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71292-2107
Practice Address - Country:US
Practice Address - Phone:318-381-9356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA305554225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist