Provider Demographics
NPI:1699217802
Name:HUMPHREY, LAKEITRA (PTA)
Entity Type:Individual
Prefix:MS
First Name:LAKEITRA
Middle Name:
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 1:714 6TH ST SW APT B
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35211-1657
Mailing Address - Country:US
Mailing Address - Phone:205-603-1003
Mailing Address - Fax:
Practice Address - Street 1:2469 STELZER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-3129
Practice Address - Country:US
Practice Address - Phone:614-416-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-07
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2133652225200000X
ALPTA8739225200000X
GAPTA004101225200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program