Provider Demographics
NPI:1417758004
Name:HUMPHREYS, MARY KATE (EDS, NCSP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATE
Last Name:HUMPHREYS
Suffix:
Gender:
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5112 ARNOLD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MCCLELLAN
Mailing Address - State:CA
Mailing Address - Zip Code:95652-1075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5112 ARNOLD AVE STE A
Practice Address - Street 2:
Practice Address - City:MCCLELLAN
Practice Address - State:CA
Practice Address - Zip Code:95652-1075
Practice Address - Country:US
Practice Address - Phone:916-844-5630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-20
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool