MEDICARE: CALLIE RAE HUMPHREY PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	20244022730	MO

General Provider Information

NPI Number	:	1609619584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CALLIE RAE HUMPHREY PTA

Provider Business Mailing Address
First Line	:	54 HOSPITAL DR
Second Line	:
City	:	OSAGE BEACH
State	:	MO
Zip	:	65065-3050
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	54 HOSPITAL DR
Second Line	:
City	:	OSAGE BEACH
State	:	MO
Zip	:	65065-3050
Country	:	US
Telephone Number	:	573-348-8000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2024
Last Update Date	:	12/23/2025

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