Provider Demographics
NPI:1619743226
Name:HUMPHRIES, MATTHEW (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:HUMPHRIES
Suffix:
Gender:M
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6089 FALCON RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-5720
Mailing Address - Country:US
Mailing Address - Phone:763-234-2512
Mailing Address - Fax:
Practice Address - Street 1:1925 WOODWINDS DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4445
Practice Address - Country:US
Practice Address - Phone:651-232-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106498225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist