Healthcare Provider Details

I. General information

NPI: 1528077633
Provider Name (Legal Business Name): EDWARD LEE HURLEY LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 STONEGATE CT # 832
FORT WALTON BEACH FL
32547-4802
US

IV. Provider business mailing address

832 STONEGATE CT # 832
FORT WALTON BEACH FL
32547-4802
US

V. Phone/Fax

Practice location:
  • Phone: 601-527-3100
  • Fax: 601-693-7910
Mailing address:
  • Phone: 601-527-3100
  • Fax: 601-693-7910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT-0079
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: