Basic Information
| Provider Information | |||||||||
| NPI: | 1508815952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUMPHRIES | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | COOKE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 727 | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275400727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195779200 | ||||||||
| FaxNumber: | 9195779292 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 W CENTER ST | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275405900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195779200 | ||||||||
| FaxNumber: | 9195779292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 8760 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7211593 | 05 | NC | MEDICAID | 078YY | 01 | NC | BCBS | OTHER |