Provider Demographics
NPI:1639669534
Name:HUMPHRIES, MICHAEL WARD (MS, CCC-SLP, BCBA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WARD
Last Name:HUMPHRIES
Suffix:
Gender:M
Credentials:MS, CCC-SLP, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3812 WEDGEWOOD CREEK DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73179-1282
Mailing Address - Country:US
Mailing Address - Phone:405-213-5113
Mailing Address - Fax:
Practice Address - Street 1:9031 SW 29TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73179-2818
Practice Address - Country:US
Practice Address - Phone:405-464-8484
Practice Address - Fax:405-883-3061
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4961235Z00000X
OK1-23-67302103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst