Healthcare Provider Details

I. General information

NPI: 1356401129
Provider Name (Legal Business Name): ROBERT BRYAN HUMPHREYS LCSW, ACSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 BRAINERD RD STE A4
CHATTANOOGA TN
37411-5336
US

IV. Provider business mailing address

1923 SULPHUR SPRINGS RD
MORRISTOWN TN
37813-5654
US

V. Phone/Fax

Practice location:
  • Phone: 423-266-4588
  • Fax: 865-342-0103
Mailing address:
  • Phone: 423-317-9344
  • Fax: 423-714-2355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4837
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: