Basic Information
Provider Information | |||||||||
NPI: | 1891160982 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUMPHREY | ||||||||
FirstName: | VANESSA | ||||||||
MiddleName: | FRANK | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | C.O.T.A | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MCGRAW | ||||||||
OtherFirstName: | VANESSA | ||||||||
OtherMiddleName: | FRANK | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | C.O.T.A | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1100 SHAWNEE ROAD | ||||||||
Address2: |   | ||||||||
City: | LIMA | ||||||||
State: | OH | ||||||||
PostalCode: | 45805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4199992030 | ||||||||
FaxNumber: | 4199910909 | ||||||||
Practice Location | |||||||||
Address1: | 682 PLEASANT DRIVE | ||||||||
Address2: |   | ||||||||
City: | WARREN | ||||||||
State: | PA | ||||||||
PostalCode: | 16365 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8147237060 | ||||||||
FaxNumber: | 8147234544 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/01/2015 | ||||||||
LastUpdateDate: | 12/01/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224ZR0403X | OP007432 | PA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | Driving and Community Mobility |
No ID Information.