Provider Demographics
NPI:1699124917
Name:HUMPHREYS, MARA ELIZABETH
Entity type:Individual
Prefix:MS
First Name:MARA
Middle Name:ELIZABETH
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MARA
Other - Middle Name:ELIZABETH
Other - Last Name:UELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:560 W MERMAID LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-4206
Mailing Address - Country:US
Mailing Address - Phone:215-990-7755
Mailing Address - Fax:
Practice Address - Street 1:560 W MERMAID LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-4206
Practice Address - Country:US
Practice Address - Phone:215-990-7755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst