Provider Demographics
NPI:1598358459
Name:HUMPHREY, LUCRETIA B (LMT LA 3780)
Entity Type:Individual
Prefix:
First Name:LUCRETIA
Middle Name:B
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:LMT LA 3780
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 ESSEN LN APT 226
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-2152
Mailing Address - Country:US
Mailing Address - Phone:318-573-5500
Mailing Address - Fax:
Practice Address - Street 1:8211 SUMMA AVE STE G
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3471
Practice Address - Country:US
Practice Address - Phone:225-267-7586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3780225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty