MEDICARE: MIRIAH LYN HUMPHREYS PTA

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	225200000X	Physical Therapy Assistant	2131547	TX

General Provider Information

NPI Number	:	1871142141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRIAH LYN HUMPHREYS PTA

Provider Business Mailing Address
First Line	:	9525 N BEACH ST STE 405
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-6438
Country	:	US
Telephone Number	:	817-502-7411
Fax Number	:

Provider Business Practice Location Address
First Line	:	9525 N BEACH ST STE 405
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-6438
Country	:	US
Telephone Number	:	817-502-7411
Fax Number	:

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

Provider Enumeration Date	:	09/09/2019
Last Update Date	:	09/09/2019

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