Provider Demographics
NPI:1841833670
Name:HUMPHRIES, PRIMROSE (LMHC)
Entity type:Individual
Prefix:
First Name:PRIMROSE
Middle Name:
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 SW 178TH WAY
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-4100
Mailing Address - Country:US
Mailing Address - Phone:954-668-3406
Mailing Address - Fax:
Practice Address - Street 1:15800 PINES BLVD # 3073
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1212
Practice Address - Country:US
Practice Address - Phone:954-668-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10678101YM0800X, 101YP2500X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst