Provider Demographics
NPI:1982132361
Name:HUMPHREY, AMY (ADC MAC SAP WV LIC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:ADC MAC SAP WV LIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2585 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1642
Mailing Address - Country:US
Mailing Address - Phone:304-697-1396
Mailing Address - Fax:304-523-8115
Practice Address - Street 1:2585 3RD AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-1642
Practice Address - Country:US
Practice Address - Phone:304-781-5138
Practice Address - Fax:304-781-5139
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WV1210103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)