Healthcare Provider Details

I. General information

NPI: 1760709190
Provider Name (Legal Business Name): HOLLY FAYE HUMPHREYS MS, ATR, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2010
Last Update Date: 06/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7851 ENON DR
ROANOKE VA
24019-1515
US

IV. Provider business mailing address

7851 ENON DR
ROANOKE VA
24019-1515
US

V. Phone/Fax

Practice location:
  • Phone: 540-265-5650
  • Fax:
Mailing address:
  • Phone: 540-265-5650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701004697
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: