MEDICARE: MR. BRIAN D. HUMPHREY M.A., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SA2647	FL

General Provider Information

NPI Number	:	1396831335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN D. HUMPHREY M.A., CCC-SLP

Provider Business Mailing Address
First Line	:	3301 COLLEGE AVE
Second Line	:	NOVA SOUTHEASTERN UNIVERSITY - SLCD
City	:	DAVIE
State	:	FL
Zip	:	33314-7721
Country	:	US
Telephone Number	:	954-262-7726
Fax Number	:	954-262-2847

Provider Business Practice Location Address
First Line	:	3301 COLLEGE AVE
Second Line	:	NOVA SOUTHEASTERN UNIVERSITY - SLCD
City	:	DAVIE
State	:	FL
Zip	:	33314-7721
Country	:	US
Telephone Number	:	954-262-7705
Fax Number	:	954-262-2847

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	09/03/2008

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