Provider Demographics
NPI:1134578388
Name:HUMPHERYS, GWENDA ANN (OTR/L)
Entity type:Individual
Prefix:MS
First Name:GWENDA
Middle Name:ANN
Last Name:HUMPHERYS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:GWENDA
Other - Middle Name:ANN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:PO BOX 1426
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-1426
Mailing Address - Country:US
Mailing Address - Phone:858-216-5661
Mailing Address - Fax:909-338-0385
Practice Address - Street 1:448 WYLERHORN DR
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:CA
Practice Address - Zip Code:92325-1426
Practice Address - Country:US
Practice Address - Phone:858-216-5661
Practice Address - Fax:909-338-0385
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AA069575225X00000X
CA1372225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist