Provider Demographics
NPI:1992950653
Name:HUMPHREY, LAURA E (PT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ELIZABETH
Other - Last Name:MACKENZIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4914
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:750 CYPRESS STATION DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5142
Practice Address - Country:US
Practice Address - Phone:502-897-6579
Practice Address - Fax:502-897-2725
Is Sole Proprietor?:No
Enumeration Date:2008-11-22
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0046772251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY004677OtherSTATE LICENSE
KY1282021Medicare PIN