Healthcare Provider Details

I. General information

NPI: 1760015242
Provider Name (Legal Business Name): AIMEE RENEE HURST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 E 5TH ST
BURLEY ID
83318-1469
US

IV. Provider business mailing address

968 W 300 S
HEYBURN ID
83336-9787
US

V. Phone/Fax

Practice location:
  • Phone: 208-678-3555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-7526
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: