Healthcare Provider Details

I. General information

NPI: 1679092969
Provider Name (Legal Business Name): TERESA SHEERILEE HURST CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2017
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E PECAN ST
ALTUS OK
73521-6141
US

IV. Provider business mailing address

1200 E PECAN ST
ALTUS OK
73521-6141
US

V. Phone/Fax

Practice location:
  • Phone: 580-379-5820
  • Fax: 580-379-5829
Mailing address:
  • Phone: 580-379-5820
  • Fax: 580-379-5829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2130
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: