Healthcare Provider Details

I. General information

NPI: 1396984571
Provider Name (Legal Business Name): KELLY ELIZABETH HURD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2009
Last Update Date: 07/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 GULL RD
KALAMAZOO MI
49048
US

IV. Provider business mailing address

1521 GULL RD
KALAMAZOO MI
49048-1640
US

V. Phone/Fax

Practice location:
  • Phone: 269-226-8133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301014109
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: