Provider Demographics
NPI:1255418562
Name:HUMPHREYS, GREGORY T (PT)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:T
Last Name:HUMPHREYS
Suffix:
Gender:M
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:PO BOX 2217
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22604-1417
Mailing Address - Country:US
Mailing Address - Phone:540-667-8975
Mailing Address - Fax:540-667-6589
Practice Address - Street 1:112 S REYMANN ST
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1730
Practice Address - Country:US
Practice Address - Phone:304-725-3632
Practice Address - Fax:304-725-8252
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00269174400000X
VA23050014992251X0800X, 225100000X
WV000269225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0156637000Medicaid
VA3810004945Medicaid
WV0156637000Medicaid
VA3810004945Medicaid
VA650000102Medicare PIN