Provider Demographics
NPI:1215076757
Name:HUMPHREY, LYDELL (MPT)
Entity type:Individual
Prefix:
First Name:LYDELL
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 LA PAZ PL
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-3407
Mailing Address - Country:US
Mailing Address - Phone:904-718-7449
Mailing Address - Fax:
Practice Address - Street 1:1268 EDGEWOOD AVE W STE 5
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-2700
Practice Address - Country:US
Practice Address - Phone:904-764-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 23096225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist