Provider Demographics
NPI:1902403124
Name:HUMPHREYS, MARANDA JOE (DC)
Entity Type:Individual
Prefix:DR
First Name:MARANDA
Middle Name:JOE
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 MANCHESTER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-2474
Mailing Address - Country:US
Mailing Address - Phone:630-868-8480
Mailing Address - Fax:
Practice Address - Street 1:2150 MANCHESTER RD STE 100
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-2474
Practice Address - Country:US
Practice Address - Phone:630-868-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013607111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor