Provider Demographics
NPI:1700439965
Name:HUMBERT, SLAYDE
Entity type:Individual
Prefix:
First Name:SLAYDE
Middle Name:
Last Name:HUMBERT
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 1:123 MAGNOLIA LN APT 123
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-3402
Mailing Address - Country:US
Mailing Address - Phone:419-388-8076
Mailing Address - Fax:
Practice Address - Street 1:3773 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3425
Practice Address - Country:US
Practice Address - Phone:614-407-8645
Practice Address - Fax:614-461-3855
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH018139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist