Provider Demographics
NPI:1831454107
Name:HUMPHREY, AMENA ALICIA (PTA)
Entity type:Individual
Prefix:MS
First Name:AMENA
Middle Name:ALICIA
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 W PRINCETON ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5305
Mailing Address - Country:US
Mailing Address - Phone:321-274-3980
Mailing Address - Fax:352-432-3911
Practice Address - Street 1:301 N HIGHWAY 27
Practice Address - Street 2:SUITE F
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2447
Practice Address - Country:US
Practice Address - Phone:352-432-3910
Practice Address - Fax:352-432-3911
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 8400101YM0800X
FLPTA 19309225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health