Healthcare Provider Details

I. General information

NPI: 1235158023
Provider Name (Legal Business Name): SHANNON R HURST M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 12/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6404 TANTAMOUNT LN
DAYTON OH
45449-3540
US

IV. Provider business mailing address

6404 TANTAMOUNT LN
DAYTON OH
45449-3540
US

V. Phone/Fax

Practice location:
  • Phone: 937-776-7810
  • Fax:
Mailing address:
  • Phone: 937-776-7810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI 0600022
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: