Healthcare Provider Details

I. General information

NPI: 1285100974
Provider Name (Legal Business Name): LAWANDA HURST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6232 S THROOP ST
CHICAGO IL
60636-1829
US

IV. Provider business mailing address

6232 S THROOP ST
CHICAGO IL
60636-1829
US

V. Phone/Fax

Practice location:
  • Phone: 708-715-5226
  • Fax:
Mailing address:
  • Phone: 708-715-5226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: