Healthcare Provider Details

I. General information

NPI: 1801422084
Provider Name (Legal Business Name): STEPHANIE HURST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date: 04/16/2023
Reactivation Date: 05/03/2023

III. Provider practice location address

4010 DUPONT CIR STE 419
LOUISVILLE KY
40207-4837
US

IV. Provider business mailing address

6749 E BROOKS DR
TUCSON AZ
85730-1629
US

V. Phone/Fax

Practice location:
  • Phone: 502-230-9633
  • Fax: 502-230-9633
Mailing address:
  • Phone: 502-230-9633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number254693
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: