Healthcare Provider Details

I. General information

NPI: 1194123703
Provider Name (Legal Business Name): JOHN HURD LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2014
Last Update Date: 12/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S KNIGHT AVE
PARK RIDGE IL
60068-4405
US

IV. Provider business mailing address

621 S KNIGHT AVE
PARK RIDGE IL
60068-4405
US

V. Phone/Fax

Practice location:
  • Phone: 847-692-3183
  • Fax:
Mailing address:
  • Phone: 847-692-3183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.016950
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: