Healthcare Provider Details

I. General information

NPI: 1457711673
Provider Name (Legal Business Name): TIMOTHY HURTAK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2016
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 W MAIN ST STE 106
DANVILLE KY
40422-1844
US

IV. Provider business mailing address

475 W MAIN ST STE 106
DANVILLE KY
40422-1844
US

V. Phone/Fax

Practice location:
  • Phone: 859-374-0238
  • Fax: 859-242-5342
Mailing address:
  • Phone: 859-374-0238
  • Fax: 859-242-5342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number254622
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: