Healthcare Provider Details

I. General information

NPI: 1598399644
Provider Name (Legal Business Name): JAMES R. HURST PH.D., HSPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6910 N MAIN ST UNIT 12
GRANGER IN
46530-9681
US

IV. Provider business mailing address

PO BOX 251
GRANGER IN
46530-0251
US

V. Phone/Fax

Practice location:
  • Phone: 574-344-4159
  • Fax:
Mailing address:
  • Phone: 574-344-4159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20041005A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: