Healthcare Provider Details

I. General information

NPI: 1760742563
Provider Name (Legal Business Name): ALLYSON L HURLBURT MFT INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 05/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 FAIRMOUNT AVE
OAKLAND CA
94611-5534
US

IV. Provider business mailing address

421 FAIRMOUNT AVE
OAKLAND CA
94611-5534
US

V. Phone/Fax

Practice location:
  • Phone: 510-839-3769
  • Fax: 510-839-3500
Mailing address:
  • Phone: 510-839-3769
  • Fax: 510-839-3500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF70430
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: