Basic Information
| Provider Information | |||||||||
| NPI: | 1235359431 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMPHREY | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 451385 | ||||||||
| Address2: | |||||||||
| City: | GROVE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743451385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187864434 | ||||||||
| FaxNumber: | 9187864435 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 HARBER RD. | ||||||||
| Address2: | |||||||||
| City: | GROVE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187864434 | ||||||||
| FaxNumber: | 9187864435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2007 | ||||||||
| LastUpdateDate: | 09/20/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3737 | OK | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.