Healthcare Provider Details

I. General information

NPI: 1255351433
Provider Name (Legal Business Name): KATHLEEN HUMPHREYS MSW, PLCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHY HUMPHREYS

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 HOSPITAL DRIVE
HANNIBAL MO
63401
US

IV. Provider business mailing address

23883 GRANITE AVE
LEWISTOWN MO
63452-2462
US

V. Phone/Fax

Practice location:
  • Phone: 573-248-5228
  • Fax:
Mailing address:
  • Phone: 573-497-2484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2005038218
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: