Provider Demographics
NPI:1972328219
Name:HUMPHRIES, ELLIOTT
Entity type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:
Last Name:HUMPHRIES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2207 DELANEY DR STE 206
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-5263
Mailing Address - Country:US
Mailing Address - Phone:336-346-4386
Mailing Address - Fax:743-208-6507
Practice Address - Street 1:618 N HOWE ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-3426
Practice Address - Country:US
Practice Address - Phone:336-346-4386
Practice Address - Fax:743-208-6507
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-21
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20914101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health