Healthcare Provider Details

I. General information

NPI: 1639335813
Provider Name (Legal Business Name): MICHAEL THOMAS HURLOCK PH.D. LMFT LPC NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 12/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 DUNHAM POND ROAD
STORRS CT
06268
US

IV. Provider business mailing address

9 DUNHAM POND ROAD
STORRS CT
06268
US

V. Phone/Fax

Practice location:
  • Phone: 860-477-0497
  • Fax: 860-477-0532
Mailing address:
  • Phone: 860-477-0497
  • Fax: 860-477-0532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number000756
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001179
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: