Provider Demographics
NPI:1508180860
Name:HUMPHREY, KRISTA A (SLP)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:A
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:A
Other - Last Name:YEOMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:5666 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2425
Mailing Address - Country:US
Mailing Address - Phone:815-226-2000
Mailing Address - Fax:
Practice Address - Street 1:5666 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2425
Practice Address - Country:US
Practice Address - Phone:815-226-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146009159235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist