Healthcare Provider Details

I. General information

NPI: 1831342120
Provider Name (Legal Business Name): STACEY HURT M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2008
Last Update Date: 09/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3362 UNIVERSITY AVE
WATERLOO IA
50701-2006
US

IV. Provider business mailing address

3362 UNIVERSITY AVE
WATERLOO IA
50701-2006
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-6571
  • Fax:
Mailing address:
  • Phone: 319-235-6571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001595
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: