Healthcare Provider Details

I. General information

NPI: 1598494486
Provider Name (Legal Business Name): TARA RENEE HURST OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 NANCY COX DR STE D
CAMPBELLSVILLE KY
42718-6835
US

IV. Provider business mailing address

104 NANCY COX DR
CAMPBELLSVILLE KY
42718-6834
US

V. Phone/Fax

Practice location:
  • Phone: 270-465-8508
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number132235
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: