Provider Demographics
NPI:1609873454
Name:HUMPHRIES, SHAWN EDWARD (MPT)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:EDWARD
Last Name:HUMPHRIES
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8052 ADELAIDE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-8031
Mailing Address - Country:US
Mailing Address - Phone:706-329-5108
Mailing Address - Fax:
Practice Address - Street 1:252 STRICKLAND PASTURE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-4019
Practice Address - Country:US
Practice Address - Phone:706-329-5108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5534225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist