Provider Demographics
NPI:1598950495
Name:HUMPHREYS, TRACY L (LMP)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:L
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1245
Mailing Address - Street 2:1212 MEADE AVE SUITE 7
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-1482
Mailing Address - Country:US
Mailing Address - Phone:509-832-0432
Mailing Address - Fax:509-786-2065
Practice Address - Street 1:1212 MEADE AVE STE 7
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-1482
Practice Address - Country:US
Practice Address - Phone:509-832-0432
Practice Address - Fax:509-786-2065
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024691225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist