Provider Demographics
NPI:1013152560
Name:HUMBERT, IANESSA ALICIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:IANESSA
Middle Name:ALICIA
Last Name:HUMBERT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:IANESSA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:98 N. BROADWAY
Mailing Address - Street 2:SUITE 413, DEPT PM&R
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231
Mailing Address - Country:US
Mailing Address - Phone:410-502-4458
Mailing Address - Fax:
Practice Address - Street 1:98 N BROADWAY
Practice Address - Street 2:SUITE 413
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-1536
Practice Address - Country:US
Practice Address - Phone:410-502-4458
Practice Address - Fax:410-502-3546
Is Sole Proprietor?:No
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04974235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist