Provider Demographics
NPI:1104290832
Name:HUMPHRIES, MEREDITH CLARK (MS, SLP-CCC)
Entity type:Individual
Prefix:MRS
First Name:MEREDITH
Middle Name:CLARK
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:MS, SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MIDLAND AVE
Mailing Address - Street 2:APT 17A
Mailing Address - City:MIDLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07432-1477
Mailing Address - Country:US
Mailing Address - Phone:919-721-7928
Mailing Address - Fax:
Practice Address - Street 1:110 MIDLAND AVE
Practice Address - Street 2:APT 17A
Practice Address - City:MIDLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07432-1477
Practice Address - Country:US
Practice Address - Phone:919-721-7928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL 60445162235Z00000X
NC11065235Z00000X
NJ41YS00823900235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist