Healthcare Provider Details

I. General information

NPI: 1982331351
Provider Name (Legal Business Name): PABLO HURTADO LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 WOODSTREAM DR
GRAND ISLAND NY
14072-1485
US

IV. Provider business mailing address

52 WOODSTREAM DR
GRAND ISLAND NY
14072-1485
US

V. Phone/Fax

Practice location:
  • Phone: 716-239-9311
  • Fax:
Mailing address:
  • Phone: 716-239-9311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number117073-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: