Healthcare Provider Details

I. General information

NPI: 1427213065
Provider Name (Legal Business Name): CANDICE LARIZ HURST PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12499 BRANTLEY COMMONS CT SUITE 101
FORT MYERS FL
33907-5676
US

IV. Provider business mailing address

12499 BRANTLEY COMMONS CT SUITE 101
FORT MYERS FL
33907-5676
US

V. Phone/Fax

Practice location:
  • Phone: 239-278-3443
  • Fax: 239-278-3550
Mailing address:
  • Phone: 239-278-3443
  • Fax: 239-278-3550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY7027
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: