Provider Demographics
NPI:1043090483
Name:HUMPHREYS, KRISTIN
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:HUMPHREYS
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 1:1017 BOLLING AVE
Mailing Address - Street 2:UNIT 407
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508
Mailing Address - Country:US
Mailing Address - Phone:781-249-4759
Mailing Address - Fax:
Practice Address - Street 1:5604A VIRGINIA BEACH BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5681
Practice Address - Country:US
Practice Address - Phone:757-455-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119009776225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist