Healthcare Provider Details

I. General information

NPI: 1962738740
Provider Name (Legal Business Name): KIM HURLEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2009
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7585 YELLOW IRIS CT
FONTANA CA
92336-0729
US

IV. Provider business mailing address

7426 CHERRY AVE STE 412
FONTANA CA
92336-4221
US

V. Phone/Fax

Practice location:
  • Phone: 909-823-2124
  • Fax:
Mailing address:
  • Phone: 626-808-3433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19301
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: