Healthcare Provider Details

I. General information

NPI: 1962862722
Provider Name (Legal Business Name): REUBEN HURD JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 MAIN ST
MELROSE PARK IL
60160-3902
US

IV. Provider business mailing address

8940 S YATES BLVD
CHICAGO IL
60617-3863
US

V. Phone/Fax

Practice location:
  • Phone: 708-681-0073
  • Fax:
Mailing address:
  • Phone: 773-933-9225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: