Healthcare Provider Details

I. General information

NPI: 1356465710
Provider Name (Legal Business Name): GLORIA HUMPHREYS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2306 BLUFF CREEK DR SUITE 300
COLUMBIA MO
65201-3552
US

IV. Provider business mailing address

2306 BLUFF CREEK DR SUITE 300
COLUMBIA MO
65201-3552
US

V. Phone/Fax

Practice location:
  • Phone: 573-874-8818
  • Fax: 573-441-2668
Mailing address:
  • Phone: 573-874-8818
  • Fax: 573-441-2668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW002779
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: