Healthcare Provider Details

I. General information

NPI: 1316137029
Provider Name (Legal Business Name): THOMAS KELLY HURSTER L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2007
Last Update Date: 07/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 SUMMIT GROVE AVE SUITE #213
BRYN MAWR PA
19010-3230
US

IV. Provider business mailing address

26 SUMMIT GROVE AVE SUITE #213
BRYN MAWR PA
19010-3230
US

V. Phone/Fax

Practice location:
  • Phone: 610-525-5030
  • Fax:
Mailing address:
  • Phone: 610-525-5030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW-002189-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: