Provider Demographics
NPI:1750538484
Name:HUMPHREY, SYDNEY NATOSHA (MSW, LCSW, RPT-S)
Entity type:Individual
Prefix:MS
First Name:SYDNEY
Middle Name:NATOSHA
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:MSW, LCSW, RPT-S
Other - Prefix:
Other - First Name:SYDNEY
Other - Middle Name:NATOSHA
Other - Last Name:KELLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW, RPT-S
Mailing Address - Street 1:P.O. BOX 51
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525
Mailing Address - Country:US
Mailing Address - Phone:580-889-0960
Mailing Address - Fax:
Practice Address - Street 1:631 E. COURT ST.
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525
Practice Address - Country:US
Practice Address - Phone:580-889-0960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TR0400X
OK45141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4514OtherLCSW