Provider Demographics
NPI:1982856969
Name:HUMPHREYS, LORI OUELLETTE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:OUELLETTE
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 MILLSWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-2224
Mailing Address - Country:US
Mailing Address - Phone:408-997-9503
Mailing Address - Fax:
Practice Address - Street 1:841 BLOSSOM HILL ROAD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123
Practice Address - Country:US
Practice Address - Phone:408-365-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18218174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18218OtherPHYSICAL THERAPY LICENSE