Healthcare Provider Details

I. General information

NPI: 1447657945
Provider Name (Legal Business Name): KELLY HURST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2014
Last Update Date: 11/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13333 PALMDALE RD
VICTORVILLE CA
92392-9364
US

IV. Provider business mailing address

13333 PALMDALE RD
VICTORVILLE CA
92392-9364
US

V. Phone/Fax

Practice location:
  • Phone: 760-241-4917
  • Fax: 760-241-8911
Mailing address:
  • Phone: 760-241-4917
  • Fax: 760-241-8911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRW8615
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: