Provider Demographics
NPI:1508801796
Name:HUMPHREY, BRIAN D (AT, ATC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:D
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 HILLTOP DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-1841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 MARTINSBURG ROAD PHYSICAL EDUCATION AND ATHLETICS
Practice Address - Street 2:MOUNT VERNON NAZARENE UNIVERSITY
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050
Practice Address - Country:US
Practice Address - Phone:740-397-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT-1028174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist