Provider Demographics
NPI:1811155880
Name:HUMPHRIES-WADSWORTH, TERRESA MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:TERRESA
Middle Name:MARIE
Last Name:HUMPHRIES-WADSWORTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 CODY AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-4116
Mailing Address - Country:US
Mailing Address - Phone:307-250-7949
Mailing Address - Fax:
Practice Address - Street 1:908 CODY AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4116
Practice Address - Country:US
Practice Address - Phone:307-250-7949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY407103TC1900X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW23252Medicare UPIN