Healthcare Provider Details

I. General information

NPI: 1942460639
Provider Name (Legal Business Name): SANDRA HURST MBA LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8361 ELLIS RD
MILLINGTON MI
48746-0359
US

IV. Provider business mailing address

PO BOX 359
MILLINGTON MI
48746-0359
US

V. Phone/Fax

Practice location:
  • Phone: 989-871-6695
  • Fax:
Mailing address:
  • Phone: 989-871-6695
  • Fax: 989-871-3663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6802035102
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801035102
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: