Healthcare Provider Details

I. General information

NPI: 1699034975
Provider Name (Legal Business Name): NATHANIEL W HURSE LADC #301333
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8557 WYOMING AVE N STE 6
BROOKLYN PARK MN
55445-1847
US

IV. Provider business mailing address

PO BOX 7508
MINNEAPOLIS MN
55407-0508
US

V. Phone/Fax

Practice location:
  • Phone: 612-203-9980
  • Fax: 612-879-3604
Mailing address:
  • Phone: 612-203-9809
  • Fax: 612-879-3604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number301333
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22145
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: