Provider Demographics
NPI:1154791986
Name:UMPHREY, LOIS
Entity type:Individual
Prefix:
First Name:LOIS
Middle Name:
Last Name:UMPHREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625-9050
Mailing Address - Country:US
Mailing Address - Phone:989-418-8477
Mailing Address - Fax:
Practice Address - Street 1:2131 COURTNEY DR
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:MI
Practice Address - Zip Code:48625-9050
Practice Address - Country:US
Practice Address - Phone:989-418-8477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7563003172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI28932020OtherANDREW ROACH
MI02980805OtherDEPARTMENT OF HUMAN SERVICES
MI1004128123OtherROBERT TOWNSEND