Provider Demographics
NPI:1790944395
Name:HUMPHREY, ERIN B (DO)
Entity Type:Individual
Prefix:DR
First Name:ERIN
Middle Name:B
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3923
Mailing Address - Country:US
Mailing Address - Phone:920-793-7420
Mailing Address - Fax:217-224-9383
Practice Address - Street 1:5300 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3923
Practice Address - Country:US
Practice Address - Phone:920-793-7420
Practice Address - Fax:217-224-9383
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1295252084P0800X
WI702172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100084233Medicaid