Provider Demographics
NPI:1932772175
Name:HUMPHREY, RYQUAISA KYELLA (LCASA, LCSWA)
Entity Type:Individual
Prefix:
First Name:RYQUAISA
Middle Name:KYELLA
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:LCASA, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 BRYSON CT APT 104
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-6372
Mailing Address - Country:US
Mailing Address - Phone:704-953-5595
Mailing Address - Fax:
Practice Address - Street 1:596 E JACKSON BLVD BLDG B
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:NC
Practice Address - Zip Code:28339-9629
Practice Address - Country:US
Practice Address - Phone:910-897-2008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP016351041C0700X
NC21744101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical