Provider Demographics
NPI:1881269074
Name:HUMPHREY, MALLORY NICHOLE (AUD)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:NICHOLE
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5428 BURTON RD
Mailing Address - Street 2:
Mailing Address - City:MUSSEY
Mailing Address - State:MI
Mailing Address - Zip Code:48014-1111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21000 E 12 MILE RD STE 111
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1156
Practice Address - Country:US
Practice Address - Phone:586-779-7610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601001020231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist