Healthcare Provider Details

I. General information

NPI: 1184776163
Provider Name (Legal Business Name): STEPHEN MICHAEL HUMPHREY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 NEW BRITAIN AVE
HARTFORD CT
06106-4033
US

IV. Provider business mailing address

602 NEW BRITAIN AVE
HARTFORD CT
06106-4033
US

V. Phone/Fax

Practice location:
  • Phone: 860-953-0406
  • Fax: 860-953-1081
Mailing address:
  • Phone: 860-953-0406
  • Fax: 860-953-1081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number001988
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: