Healthcare Provider Details

I. General information

NPI: 1386462331
Provider Name (Legal Business Name): MARGO HURLOCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 PINE CREST RD
TIJERAS NM
87059-7646
US

IV. Provider business mailing address

4 PINE CREST RD
TIJERAS NM
87059-7646
US

V. Phone/Fax

Practice location:
  • Phone: 704-305-1782
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1648
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: