Provider Demographics
NPI:1538465356
Name:HUMPHREY, TRACEY E (MSPT)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:E
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 OPEKISKA RD
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-8753
Mailing Address - Country:US
Mailing Address - Phone:304-612-4945
Mailing Address - Fax:
Practice Address - Street 1:202 OPEKISKA RD
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-8753
Practice Address - Country:US
Practice Address - Phone:304-612-4945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT 001565225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist