Provider Demographics
NPI:1609211408
Name:HUMPHREY, KATHERYN M (PTA)
Entity Type:Individual
Prefix:
First Name:KATHERYN
Middle Name:M
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8425 PILLSBURY AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-2243
Mailing Address - Country:US
Mailing Address - Phone:704-340-8884
Mailing Address - Fax:
Practice Address - Street 1:8100 HIGHWOOD DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-1006
Practice Address - Country:US
Practice Address - Phone:952-830-9586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1572225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant