Healthcare Provider Details

I. General information

NPI: 1255418562
Provider Name (Legal Business Name): GREGORY T. HUMPHREYS P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 S REYMANN ST
RANSON WV
25438-1730
US

IV. Provider business mailing address

PO BOX 2217
WINCHESTER VA
22604-1417
US

V. Phone/Fax

Practice location:
  • Phone: 304-725-3632
  • Fax: 304-725-8252
Mailing address:
  • Phone: 540-667-8975
  • Fax: 540-667-6589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number00269
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2305001499
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number000269
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305001499
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: