Provider Demographics
NPI:1417456922
Name:HUMPHREY, SUSAN LOUISE (LBA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LOUISE
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-3840
Mailing Address - Country:US
Mailing Address - Phone:276-238-8885
Mailing Address - Fax:276-238-8822
Practice Address - Street 1:106 CALHOUN ST
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-3840
Practice Address - Country:US
Practice Address - Phone:276-238-8885
Practice Address - Fax:276-238-8822
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000932103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst