Provider Demographics
NPI:1215685078
Name:HUMPHRIES, REBECCA LYN
Entity type:Individual
Prefix:MISS
First Name:REBECCA
Middle Name:LYN
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2556 POND DR N
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27896-1700
Mailing Address - Country:US
Mailing Address - Phone:252-722-4808
Mailing Address - Fax:
Practice Address - Street 1:2416 BEDGOOD DR SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-8515
Practice Address - Country:US
Practice Address - Phone:252-265-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-11
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 106H00000X
NC12533A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program