Healthcare Provider Details

I. General information

NPI: 1013241140
Provider Name (Legal Business Name): BRYAN LANCE HURT PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 PAN AMERICAN FWY NE
ALBUQUERQUE NM
87107-4786
US

IV. Provider business mailing address

3405 PAN AMERICAN FWY NE
ALBUQUERQUE NM
87107-4786
US

V. Phone/Fax

Practice location:
  • Phone: 505-222-0324
  • Fax: 505-222-0301
Mailing address:
  • Phone: 505-222-0324
  • Fax: 505-222-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number681
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: