Basic Information
| Provider Information | |||||||||
| NPI: | 1720004567 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUMPHREYS | ||||||||
| FirstName: | NONNIE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5344 FOREST RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483463478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488841104 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6770 DIXIE HWY | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483462087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489222300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6801064385 | MI | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | 6801064385 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.