Healthcare Provider Details

I. General information

NPI: 1225136799
Provider Name (Legal Business Name): ROSWITHA HELENA HURST LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ROSE H HURST MA

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 S ABILENE AVE
PORTALES NM
88130-6208
US

IV. Provider business mailing address

109 S AVENUE F
PORTALES NM
88130-5954
US

V. Phone/Fax

Practice location:
  • Phone: 575-226-3494
  • Fax: 575-226-3495
Mailing address:
  • Phone: 575-714-1326
  • Fax: 575-226-3495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0091591
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: