Healthcare Provider Details

I. General information

NPI: 1184979601
Provider Name (Legal Business Name): SHOSHANA L HUMPHREYS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 OLD POST ROAD
BEDFORD NY
10506-0002
US

IV. Provider business mailing address

PO BOX 266
GOSHEN NY
10924-0266
US

V. Phone/Fax

Practice location:
  • Phone: 914-234-4445
  • Fax: 914-234-4446
Mailing address:
  • Phone: 845-615-1585
  • Fax: 845-615-1576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number035264
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: