Healthcare Provider Details

I. General information

NPI: 1336893932
Provider Name (Legal Business Name): SHANE PATRICK HURLEY LP MHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2022
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 PLANK RD
CLIFTON PARK NY
12065-2046
US

IV. Provider business mailing address

104 W SUNNYSIDE WAY APT 223
TROY NY
12180-1495
US

V. Phone/Fax

Practice location:
  • Phone: 518-545-4691
  • Fax:
Mailing address:
  • Phone: 585-435-7080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: